Health care systems should emphasize behavioral and mental health
As a family medicine resident at a large academic medical center I feel lucky to have the opportunity to interact with different disciplines within the health care field. I particularly appreciate working with the Division of Community Health in the Department of Community and Family Medicine, with whom we work hard to support many shared goals, such as those found within our residency’s population health curriculum.
Resident exposure to community care management programs, local health initiatives, community partners and corresponding issues have ultimately allowed me to better understand what our individual patients are navigating and facing beyond the walls of Duke Family Medicine Center. It has also granted me, as a provider of health care services, a more in-depth look at our community health resources and a better way to understand some of the health care disparities that exist here in Durham.
Reflections on the Community Health Rotation
Memories from my recent community health rotation range widely, from hearing the joyous voices of two women singing their appreciation for diabetic services at Healing with C.A.A.R.E., Inc., to a homeless man being removed from a local shelter for marijuana paraphernalia found amongst his belongings.
As a physician in training who deals daily with the results of chronic disease management, such as with obesity, diabetes and hypertension, I cannot help but think about the underlying causes of many of the chronic problems that our community partners are dealing with. I believe that chronic disease processes are often caused by, for example, basic behavioral health issues, such as an individual’s unhealthy eating habits, a lack of exercise, poor sleep hygiene, smoking, or substance abuse. Often, underlying many of these causes one will also find mental health problems, such as depression, anxiety or substance dependence, with these problems reinforcing behaviors or making bad habits hard to break. Considering how large the impact a patient’s behavior has on their health, I naturally became curious during the Community Health Rotation about the local behavioral and mental health partners, plus interventions that might exist here in Durham.
On the rotation I learned about partners such as El Futuro and the incredible example it serves as a community partner able to identify and address a mental health care disparity that would otherwise go unaddressed within our local Spanish-speaking population. So, too, was I impressed when touring the Durham Recovery Response Center, witnessing the resources and ability at hand to address acute mental health care crisis. One could certainly not survey Durham without also paying homage to TROSA and the amazing job this community partner does with providing opportunities for those struggling with substance abuse.
However, the deeper I looked into the behavioral and mental health care network within the Durham region and within our state, the more I began to learn how complicated navigating the services here can be at times. For example, while the Alliance Health Care Management network is a local gatekeeper that seems ready and able to address our local populations’ mental health issues in many instances, you may be surprised to learn that others with behavior and mental health care needs, just as local, receive referrals to Cardinal Health Care, far to the north of Durham, depending solely on their local address.
I quickly became confused when navigating the two mental health care networks, as referral times can sometimes be lengthy and unfortunately confusing for patients. While I could find several shining examples of mental health care organizations locally within the community, on the whole the system started to seem stretched thin, fragmented within our state, and, for me as a provider — never mind a patient struggling with mental health illness — difficult to understand and navigate. I started to wonder whether mental health care services were as easy to access for our population.
Are we ready and able to counsel our patients in need?
A mental health care provider within the Division of Community Health in our department shared with me during the rotation that several decades ago North Carolina seemed to make a dramatic shift from a robust system of inpatient mental health care services to a more preventive outpatient approach. The idea for this move was seemingly to increase access to mental health care services, whilst also keeping individuals within the community instead of inpatient psychiatric facilities. However, since that time it would seem to me that outpatient services within our community have dried up a bit further than anticipated, or been subjected to tighter control, tied up within local gatekeepers or managed care organizations dispensing services.
The sad thing, in my opinion, is that the presence of mental health care services seems more and more distant for many within our community.
The experience has taught me that many needs are going unmet in relationship to health outcomes overall. With primary care services stretched more and more thin these days, and a lack of reimbursements for behavioral counseling within primary care, I do wonder at times who is truly ready and able to counsel patients in need, and how could we be doing a better job?
Both in medical school and residency, on any given day in our local hospital I could imagine 50 to 100 possible substance abuse consults. These consults could be for obstructive pulmonary disease in a smoker, acute pancreatitis or liver disease in the setting of alcohol abuse, endocarditis for an IV drug abuser, or ketoacidosis for a patient with poor eating habits. These acute or chronic disease exacerbations are huge drains on our health care system.
You may wonder how many behavioral substance abuse counselors there are within our hospitals to counsel these patients. The answer is not enough, to put it bluntly. Common sense, in my opinion, would say that if health care is struggling with the cost of chronic disease management problems such as these, chronic disease is largely the result of our patients’ behavior and lifestyle choices, and behavior and lifestyle choices are most effectively modified by counseling and behavioral modification, then why aren’t we making these services more readily available within our communities, our hospitals, and supporting those better who need to provide these services? Instead we seem to increase training and access to specialists, those unwilling or untrained to address the real underlying issues which are truly driving chronic disease processes. And as a result, patients end up with a doctor for every symptom.
The Community Health Rotation taught me the importance of recognizing our local partners that are working within behavioral health and that behavioral providers within primary care and the mental health disciplines could be supported more within many of our local and state-wide political systems. Crucial problems affecting long-term health outcomes for our patients could continue to go unaddressed if we do not recognize the importance of behavioral counseling within our health care system.
Jonathan Hedrick is a first-year resident with the Duke Family Medicine Residency Program. Email jonathan.hedrick@duke.edu with questions.
Editor’s note: Duke Family Medicine residents guest blog once a month.