Embedding a Psychologist Into Primary Care Increases Access to Behavioral Health Services

Abstract

Background: Patients commonly report psychological issues during primary care visits; however, few patients will follow through with a referral for behavioral health services at an outside facility. Therefore, patients may benefit from having psychologists embedded into primary care clinics. The purpose of this study was to determine who saw a primary care psychologist and to investigate which patient characteristics predicted who was more likely to attend subsequent visits with behavioral health services. Methods: There were 96 patients referred to a primary care psychologist by their primary care physician. Chart reviews were conducted to obtain patient characteristics and to determine whether the patients attended a subsequent visit with behavioral health services after the initial evaluation. Results: There were 84.4% of patients who completed an initial evaluation with a psychologist and 15.6% either cancelled or did not show for this evaluation. Of those who completed the initial evaluation, more than half had never received treatment from a behavioral health specialist. Of the 70.4% patients recommended to attend additional behavioral health treatment, 54.4% of patients attended a subsequent visit. Gender, age, race, years of education, and whether a patient had previous behavioral treatment did not predict who was more likely to attend a subsequent behavioral health visit after the initial evaluation. Conclusions: Embedding a psychologist in a primary care clinic leads to increased access to behavioral health services, especially among patients who may not seek out these services themselves or follow through with a physician’s referral to an outside behavioral health clinic.

Patients commonly present to primary care visits with psychological issues or concerns. Approximately 20% to 25% of primary care patients have a mental health disorder ¹ ; however, many of these patients are only treated by their primary care physician (PCP).^2,3 Specifically, it is estimated that 60% to 70% of patient visits are driven by psychiatric symptoms and these patients often only seek help from PCPs rather than a behavioral health professional.^2,3 It is well known that mental health affects physical health outcomes, but only 10% of patients who are referred by their PCP to see a behavioral health specialist at an outside clinic will follow through with the referral. ⁴ Given this, patients may receive better treatment if there is a multidisciplinary, collaborative approach within primary care clinics. One mechanism by which this approach can be implemented is by embedding health psychologists into primary care clinics.

The number of primary care clinics with an integrated psychologist is increasing, ⁵ and this approach to primary care enhances the quality of treatment for patients. ⁶ Integrated primary care contributes to improvement in depression, better adherence to medications, lower mortality rates, and overall improved health outcomes for patients.^7,8 Although there are many benefits to integrated primary care, this is still a growing area of research. There has been little research regarding characteristics of patients who see a primary care psychologist. It is also unclear which patients are more likely to engage in additional behavioral health treatment after an initial evaluation with a psychologist in a primary care clinic. Therefore, the aims of this study were (a) to determine the prevalence of patients who saw a primary care psychologist and the characteristics of these patients, (b) to estimate the number of patients who had a subsequent visit with behavioral health services, and (c) to investigate whether there were predictors of who was more likely to attend a subsequent visit with behavioral health services.

Methods

Participants

Ninety-six patients were referred to a primary care psychologist by PCP in an outpatient Internal Medicine Clinic. These patients were referred over a 3-month period. The PCPs referred patients based on their clinical judgment and whether they thought the patients could benefit from behavioral health services. Patients in this clinic are also routinely screened for depression by the medical assistants using the Patient Health Questionnaire (PHQ-9 ⁹ ) and so PCPs may have referred a patient because of an elevated PHQ-9 score.

Procedure

This study was approved by the hospital’s institutional review board. Patients completed an evaluation by a psychologist and/or a supervised psychology intern in the Internal Medicine Clinic between September 2013 and November 2013, which was when this service first began in this clinic. The Internal Medicine Clinic is an academic medical home that uses a multidisciplinary, team-based approach to provide patient-centered care in an urban setting. This medical home is staffed with 17 senior staff physicians, several physician extenders, a registered nurse diabetes educator, a clinical pharmacist, and is the continuity clinic for 88 Internal Medicine residents. There is 1 staff psychologist and 1 psychology intern who can see up to 5 patients in 1 day at the clinic. The initial evaluation with the psychologist or psychology intern included a semistructured interview, which was a diagnostic DSM-IV-TR interview and also inquired about the patients’ history of psychiatric treatment. The initial evaluation also included several screening measures including the Montreal Cognitive Assessment to assess for cognitive functioning, ¹⁰ the Hospital Anxiety and Depression Scale to assess for current symptoms of depression and anxiety, ¹¹ and the Insomnia Severity Index to assess for current sleep difficulties. ¹² After completing the initial evaluation, the psychologist provided recommendations and brief interventions to the patients. Recommendations often included attending subsequent visits with behavioral health services following the initial evaluation.

Chart reviews were conducted to determine patient characteristics, whether patients were recommended to attend subsequent visits with behavioral health services, and whether the patients did attend a subsequent visit with behavioral health services within the hospital system.

Statistical Analysis

Descriptive statistics were calculated to determine prevalence of patient characteristics, history of psychiatric treatment, patients who were recommended to have further behavioral health services, and patients who attended subsequent behavioral health visits. Independent-samples t tests were conducted to determine whether there were differences in gender and age between those who did and did not complete the initial evaluation. Independent-samples t tests and χ² analyses were conducted to determine whether gender, race, age, years of education, and history of psychiatric treatment predicted whether patients were more likely to attend a subsequent visit.

Results

Characteristics of Patients

Of the 96 patients referred for a psychological evaluation, 81 (84.4%) patients completed an initial evaluation with a psychologist and 15.6% (n = 15) either cancelled or did not show for their appointment.

The majority of patients who completed the initial evaluation were female (71.6%, n = 58) with an average age of 53.78 years (SD = 17.53). Most patients self-identified as Black (84%, n = 68), 9.9% identified as Caucasian (n = 8), 3.7% identified as other or as multiracial (n = 3), and 2.5% preferred to not respond (n = 2). More than half of the patients referred had never received treatment from a behavioral health specialist (56.8%, n = 46). There were no differences in age (M = 52.67 years, SD = 13.62), t = −0.23, P = .82, or gender, χ² = 0.15, P = .70, between those who did and did not complete the initial evaluation. Of those who did not complete the initial evaluation, 66.7% (n = 10) were female.

Subsequent Visits With Behavioral Health Services

After the initial evaluation with the psychologist, 70.4% (n = 57) of patients were recommended to attend additional visits with behavioral health to assist with the symptoms the patients reported. Of these, 54.4% (n = 31) attended a subsequent visit with a behavioral health specialist for further treatment. There were no predictors of who was more likely to attend a subsequent visit with behavioral health after the initial evaluation (see Table 1). Specifically, there were no differences among gender, age, years of education, and those who identified themselves as Black or Caucasian. Those who had never seen a behavioral health specialist were just as likely to attend a subsequent visit as those who had previously sought behavioral health services.

Table 1.

Characteristics of Patients Who Did and Did Not Attend a Subsequent Visit With Behavioral Health Services.

Variable	Follow-up Mean (SD)	No Follow-up Mean (SD)	t	P
Age	51.71 (18.86)	56.04 (15.68)	.93	.36
Years of education	12.73 (2.88)	12.68 (2.34)	.08	.94
Variable	Follow-up % (n)	No Follow-up % (n)	χ2	P
Gender			.26	.61
Male	60.0 (9)	40.0 (6)
Female	52.4 (22)	47.6 (20)
Race			.72	.40
Black	53.1 (26)	46.9 (23)
Caucasian	75.0 (3)	25.0 (1)
Prior behavioral health treatment			.32	.57
Yes	57.6 (19)	42.4 (14)
No	50.0 (12)	50.0 (12)

Discussion

Having a psychologist embedded in an outpatient Internal Medicine Clinic leads to increased access to behavioral health services for patients. Rates of initial and subsequent visits at behavioral health appointments in our sample are often higher than traditional behavioral health clinics. ¹³ For example, patients in a behavioral health clinic typically have a no-show/cancellation rate ranging from 30% to 75% for an initial appointment, and 20% to 60% for attendance at subsequent visits. ¹³ Additionally, the number of patients who agreed to see a psychologist in a primary care clinic is much higher than those who followed through with a referral from their PCP to go to an outside behavioral health clinic. ⁴ Our low no-show/cancellation rate might be because patients are often able to be seen the same day as their PCP visit. Patients who are able to quickly obtain psychiatric services are more likely to appear for their initial appointment, and the failure to keep the intake appointment will increase with each day of appointment delay.^14-16 Additionally, when patients are seen the same day, this eliminates other common reasons for no-show rates, including logistical issues such as trouble getting off work, child care, transportation, and cost. ¹⁷

Another reason for the low no-show/cancellation rate could be that patients are seen in a primary care clinic rather than a behavioral health clinic. This may be due to the familiarity of the office staff, location, and means of transportation. More importantly, having a psychologist integrated in primary care may reduce the stigma of seeing a psychologist, which is often a concern for patients, ¹⁸ especially since services are provided in the same location as the patients’ medical services. ¹⁹ Hence, a psychologist in primary care can make referrals and scheduling easier for patients.

Unexpectedly, although our patients had high rates of attending subsequent visits with behavioral health after the initial evaluation, this was independent of patient characteristics. This finding was not aligned with previous research delineating lower utilization among elderly persons, racial/ethnic minorities, and males.^20-26 Stigma is considered a potential explanatory factor for the lower rate of behavioral health treatment among men, ²⁷ and this could also be a contributing factor among the other groups. It is possible that seeing a psychologist in a primary care clinic helped reduce the stigma surrounding behavioral health services. Furthermore, many of these patients had never seen a behavioral health specialist, which was surprising given that a history of psychiatric services is associated with attendance. ²⁸ This suggests that having a psychologist within a primary care setting reaches patients who may not otherwise seek services and is successful at encouraging them to engage in further behavioral health treatment. It is imperative to have patients engage with behavioral health services when needed because when patients receive appropriate psychological care, there are better medical outcomes for patients as well as lower medical costs.^7,8,29 Perhaps other variables need to be considered to determine what predicts attendance at subsequent visits. Future research should consider severity of the psychological issue, stigma or attitudes regarding behavioral health services, socioeconomic status, and whether the patient has logistical issues (ie, work, child care, transportation, and cost).

Although this study demonstrates that having a psychologist integrated in primary care facilitates patient access to behavioral health services, there are several limitations. As described above, we were only able to track patients within our medical system. Many patients may be attending additional visits with behavioral health outside the system so the rate of patients attending subsequent visits could be even higher. Additionally, the sample size is relatively small which may make the sample underpowered to detect predictors regarding who may be more likely to attend a subsequent behavioral health visit. Future research should be conducted to determine whether these results can be replicated with larger sample sizes. Finally, although patients are attending additional visits with behavioral health services, we do not yet know whether their health outcomes improve. Therefore, future research should examine mental and physical health outcomes prospectively.

This study provides support for the continuing integration of psychologists in primary care. This integration improves access to behavioral health services for patients, especially among those who may not seek these services themselves or follow through with a referral to an outside behavioral health clinic.