Promoting Behavioral Health Integration in American Indian Primary Care Clinics

A Patient-Centered Perspective

Seneca Nation health system logo with ginger leaves

Seneca Nation Health System logo

Behavioral health disorders — any mental illness or substance abuse disorder — are highly prevalent in primary care patients but are often underdiagnosed and undertreated, compromising treatment outcomes. Identifying populations and geographic settings that lack access to effective care is only the first step in addressing mental health needs and successfully providing requisite care to underserved and at-risk populations.

With widespread disparities of care in underserved and rural areas, it is important to respond to the critical need for increased access to mental health and substance abuse screening and treatment to meet unmet needs of the American Indian population.

ginger root

The Seneca Nation Health System logo is an ancient Iroquois floral design adapted to depict the heart-shaped leaves of the ginger plant, which is homeopathic and indigenous to the Seneca territories.

As members of federally recognized sovereign nations, American Indians are unique among minority groups in the U.S. With their history of trauma, discrimination and forced relocation from traditional lands, American Indians have encountered tremendous adversity, which has significantly contributed to their representation among populations with high need for mental health care. American Indians have extraordinary resiliency, but more accessible and effective interventions are needed to promote these intrinsic strengths. Better access to care and other psychosocial resources can enhance their health and well-being.

Collaboration for quality care

UB School of Nursing has received a two-year, $1.0 million grant funded through Health Resources and Services Administration to partner with the Seneca Nation Health System to increase access to mental health and substance abuse screening and treatment at two facilities, the Lionel R. John Health Center located in Salamanca, New York, and the Cattaraugus Indian Reservation Health Center in Irving, New York.

The grant has funded the development of an interprofessional collaborative practice team – consisting of members of the Seneca Nation and the University at Buffalo – who will lead screenings and behavioral health care to augment traditional primary care with onsite behavioral health services. This will also provide clinical training to FNP and PMHNP graduate students in the UB Schools of Nursing and Social Work.

Collaborative care is an evidence-based integrated care model that provides high quality mental health care in familiar settings. It utilizes a patient-centered workflow that begins with a care manager first screening for depression, substance abuse and signs of post-traumatic stress disorder and suicide risk, and then notifying primary care providers of any issues that arise. If a patient screens positive for one of these problems, the provider briefly educates the patient about health risks associated with these behaviors and offers a “warm handoff” to introduce the patient to a behavioral health counselor, or care manager, for on-site services. This may include discussing health risks, identifying benefits of treatment using evidence-based behavioral models, and continually assessing patient compliance and effectiveness of treatment modalities. The integrated care offers a trauma-informed approach that promotes a sense of safety and trustworthiness, and it removes the natural barriers to seeking treatment while culturally tailoring the services to meet the needs of the individual.

5 Core Principles of Collaborative Care Source: AIMS Center, University of Washington, Psychiatry & Behavioral Sciences – Division of Population Health 1. Patient-Centered Team Care a. Providers use shared care plans informed by patient goals to improve patient experience and reduce duplicate assessments. 2. Population-Based Care a. Care team tracks a shared, defined patient group and provides personalized, caseload-focused consultations for patients who are not improving. 3. Measurement-Based Treatment to Target a. Uses clinical outcome measures to adjust treatment plans for each patient until clinical goals are reached. 4. Evidence-Based Care a. Efficacy of treatments offered to patients is supported by credible research evidence. 5. Accountable Care a. Providers are reimbursed for care quality and clinical outcomes, not just volume of care provided.

5 Core Principles of Collaborative Care (Source: AIMS Center, University of Washington, Psychiatry & Behavioral Sciences – Division of Population Health)

The grant objectives include utilizing two evidence-based behavioral health models, “Screening, Brief Intervention and Referral to Treatment” and “Improving Mood—Promoting Access to Collaborative Treatment,” that are being implemented as part of practice change in the primary care setting. These interventions offer better screening protocols that help to identify patients with substance abuse and mental health problems.

The integrated care manager works with the primary care provider by sharing behavioral health insights and partners with a psychiatric consultant who assists with diagnosis and medications. The care manager can then provide the patient with counseling using evidence-based psychotherapy. This includes several options such as motivational interviewing, which utilizes motivation to change and augment problem behaviors, or cognitive behavioral therapy, which improves health by helping people understand how their thoughts and feelings affect their behavior. The care manager also helps to improve the effectiveness and compliance of medications by partnering with a psychiatric consultant and working alongside the primary care provider and patient.

“American Indians have endured both limited and differential access to resources, creating disparities in health status and a lack of exposure to quality health care when compared with other racial and ethnic groups,” says principal investigator Yu-Ping Chang, associate professor and associate dean for research and scholarship in the School of Nursing.

“American Indians also have increased risks for many health conditions, including mental health and substance abuse, which leads to higher mortality rates.”

The project also includes educational and experiential learning that emphasizes cultural sensitivity about American Indian health care beliefs, customs, family dynamics, communication patterns and social determinants of health, which can impact access and adherence to mental health care.

Clinic staff will be surveyed regarding their perceptions of the effectiveness of the behavioral health integration and their level of confidence in being able to deliver effective behavioral health treatment. Patients will be surveyed on their awareness of treatment options and views on treatment effectiveness.

In addition to Chang, the UB team consists of Kurt Dermen, PhD, UB Research Institute on Addictions; Margaret Moss, JD, PhD, RN; Nancy Campbell-Heider, PhD, RN, FNP-C, CARN-AP; Patti Nisbet, DNP, PMHNP-BC; and Sabrina Casucci, PhD, UB School of Engineering and Applied Sciences.

“There is compelling evidence that suggests creating an integrated primary care practice increases the number of patients receiving effective, evidence-based treatment, and that those patients feel better faster,” says Thane Schulz, ; and Thane Schulz, LMSW, certified care manager and former project coordinator.

“Being referred out to counseling can be intimidating and ambiguous, but this model helps reduce those feelings since it is intrinsically trauma-informed. The patient is already in a safe place and trusts their primary care provider.”

That trusted provider, Shulz explains, then introduces the patient to a care manager who champions collaboration, offers choices in treatment and ultimately empowers the patient.

“Those patients can get back to work, back to their families and back to the healthy activities they enjoy. The repeated, historical traumas that American Indians have experienced generationally makes this project even more critical.”

-DONNA A. TYRPAK, THANE SCHULZ