A Secret of Behavioral Health Integration: The Handoff

We learned by experience at Kaiser that a good model is to have health professionals organize themselves into disease-based groups, such as a Low Back Pain Clinic or a Diabetes Clinic. in this way, the behavioral health-care specialists, or psychologists would be integrated with the other health care practitioners. the psychologist would learn the particular disorder very well, and address the behavioral issues peculiar to that disorder. We also noticed that the doctors would have 15-minute interviews. In the integrated system, the physician would see that a certain patient had a psychological issue, and might profit by seeing the psychologist. So the physician would say: "Let's go see Dr. Cummings," and there would be a hand-off to the psychologist. Now, this is the subtlety we discovered, and one that can make all the difference in the world as to whether the patient will continue in treatment with the psychologist. The primary care physician stays in the room while the psychotherapist starts the informal session with the patient.

L.T.: So this technique is something like "log rolling." That is, you leave one foot on the log you are leaving and the other foot on the log you are going toward. You have a foot on each log at the same time. So you also have two doctors in a room at once, holding the patient's band so to speak, until it comes time to leave the patient with the behavioral health-care professional

N.C.: Yes, that's how it was done. And that difference helped the patient continue with the behavioral treatment. Without this seemingly simple touch, patient compliance was not very good, but with this idea of the handoff, compliance jumped to 90 percent. And the saving in medical costs was tremendous. This became part of the fabric of the health system at Kaiser.

In other medical care systems, the doctors do not want to bother with the psychological problems of their patient. Most often they don't know what to do even if they do see the problem. In an enlightened place, perhaps 40% of patients needing a psychologist are recognized and referred, and of these, only 10% get into therapy. Contrast this with an integrated system in which 90 percent of those who need psychological help would be referred or handed off, and 80 percent would continue in treatment. Thus, in the integrated system, there would be a lot more efficiency in having the patient get the correct treatment.

In contrast, the carve-out has heightened the problem, since the patient is going not only to a different building, but to a different company. This makes patients reconsider whether or not they want to see a "shrink." Most choose to avoid seeing the psychotherapist. Also, having the patient accept psychological help is only half the battle. The other half is making sure that the psychotherapist can deal with these patients in a flexible way.

I learned a very important lesson during this developmental time at Kaiser. You need to hire the right people up front. Many psychologists did not want to work in such an integrated setting because they felt that they were losing their identity. It was difficult to train them into this more integrated and flexible model, to have them adjust their point of view toward doing psychological work in ways they had not previously learned.

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