Putting mental health services into primary care clinics is an idea that’s gained traction in recent years. In Texas, it came about partly out of necessity after the state mental health care system streamlined its services over a decade ago. An unintended consequence was that people with less severe mental health issues ended up seeking care in community clinics that weren’t fully equipped to care for them.
Today, what’s known as integrated behavioral health care can bring mental health services to people through their family doctor – and also reach those who normally may never see a counselor. And It seems to be gaining momentum in the Rio Grande Valley.
At the Mercedes, Texas location of Nuestra Clinica del Valle, the waiting room is nearly at capacity on a July afternoon. The federally-funded agency has 11 community health clinics that primarily serve low-income and uninsured patients. Many of them come for routine physical care, but while they’re here, some of them may get another service.
Veronica Gonzalez is director of behavioral health for the agency, and a program manager for the Sí Texas grant program.
“We go in there, we speak to the patient briefly and kind of introduce them to services as to what counseling is…” she says.
The agency started integrated behavioral health programs across south Texas. Something Gonzalez says was long overdue.
“In this region, the south Texas region, there was a need for it. It was time for it to happen,” Gonzalez says.
That’s because community health clinics have recently noticed an increasing need for mental health services. They also realized that physical health conditions like diabetes are harder to treat without also addressing a patient’s mental health. It’s the basic principle of integrated behavioral health care.
“Individuals need to make some sort of behavioral change…to maintain their health,” Gonzalez says.
It may sound simple, but bringing mental health services into a primary care clinic is a complicated process. It can require changes in how providers are paid and how medical records are shared. It can also be a hard adjustment for doctors.
“In the beginning it was difficult for them to allow us to integrate into their flow but I believe that that’s just something thats gonna come across wherever you attempt to change the way a system already works….And what happens is that people find out that we’re doing this and they kind of come and they’ve asked me, like, ‘How are you doing this? Can we see your model?’” Gonzalez says.
People in the Rio Grande Valley experience mental health disorders like people anywhere else. But the region faces economic and cultural challenges that make integrated behavioral health care both especially difficult to implement and also vital. It can be harder to recruit mental health professionals in the Valley. And state data show nearly 30 percent of people in the region live in poverty – almost twice the state average. On top of that, Hidalgo and Cameron counties have some of the highest rates of uninsured people in the state. Meaning programs like the one at Nuestra Clinica mostly rely on grants and state and federal funding.
But Sí Texas data manager Marco Mata says the reason integrated care is vital in the Valley is because of social stigma.
“It’s ingrained in our culture, our Hispanic culture, our machismo culture…. Like, either you adapt or figure it out all on your own….It’s mostly [due] to that lack of education,” Mata says.
By getting mental health care at the primary care clinic, no one ever has to know that a patient saw a counselor. At Nuestra Clinica, the counseling is actually part of the doctor appointment.
David Lopez received integrated care through a Sí Texas program near Corpus Christi.
“They’re really killing two birds with one stone, which is really one of the best ideas ever…” he says.
He says he’s less likely to care for his physical health because of his mental health issues. When the care is combined, he can get help before an illness becomes a crisis.
“I’d wait till the very end when I’m really sick and I’d go to the emergency room ‘cause I didn’t have a primary care physician,” Lopez says.
For all its momentum in public health, integrated care isn’t as common in the private sector. But Brownsville pediatrician Dr. Asim Zamir has made a version of it work for over a decade. He decided to make a change to his clinic after a tragedy with one of his infant patients: The baby died in a hot car while his mom ran into a store to fill a prescription.
“So that day, I thought, you know I think the need is that this mother should have one-stop shopping – [that] idea came to my head – where she can get all the services,” Zamir says.
Zamir added mental health services because he says there are so few child psychiatrists in the region. And he says mental health problems have gotten worse among kids in recent years.
“In [the] past two years, I have seen so much increase in suicidal thoughts and attempt that it’s really overwhelmed us,” he says.
Zamir doesn’t blend his business with his mental health providers. Instead, they just have an office in his clinic, rent-free. He refers patients to them, and they can come back to Zamir if they need a prescription.
Dr. Ernest Buck is chief medical officer for Driscoll Health Plan, an insurer that covers south Texas. He says complete integration may seem too risky for some private practices.
“It’s hard to start a new model where a physician’s practice could be put at risk, particularly at Medicaid rates….And additionally, if we’re the only plan willing to talk about it… you know, you don’t transform a practice for one payer,” Buck says.
Back at Nuestra Clinica, Data Manager Marco Mata says the next phase of Sí Texas is to keep its programs going once the grant runs out. One way is to show integrated care is helping patients. He tries to do this through periodic depression surveys. But he says it’s hard keeping patients in the study at a time when some living near the border are more wary of divulging personal information.
“We started with a certain amount of people and we missed out on impacts and follow-ups on a good chunk of our sample…. It could have supported our results in the end, and just to not have that retention that we were hoping for, it’s disheartening,” Mata says.
But Mata says so far, the data show that integrated care is helping, though results are far from final. What is certain is that he and his colleagues are determined to make integrated health care more widely available to those in the Valley—especially for those who may never have thought about their mental health before.