Introducing the Health & Wellness Podcast: IHT at Sanford

Program supports mental health with integrated therapists in primary care clinics

Dr. Jeff Leichter talks about the integrated health therapists program at Sanford

Episode Transcript

Courtney Collen (Host): Hello and welcome. You are listening to the Health and Wellness Podcast brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. This series begins new conversations and continues the important ones, all designed to keep you well physically and mentally featuring our Sanford Health experts. Today, we are talking with Jeff. Leichter, PhD, a clinical psychologist and the lead administrator for behavioral health integration for Sanford Health.

Dr. Leichter, glad to have you here.

Dr. Jeff Leichter (Guest): Thanks for having me Courtney. It’s a pleasure to be here.

Host: We’re talking specifically about the Integrated Health Therapist (IHT). Explain what that’s all about.

Dr. Leichter: Yeah, that’s a program that we’re really proud of. It came about as a result of a large grant that Sanford Health was awarded by the Centers for Medicare & Medicaid Services (CMS) back in 2012. It was a three-year, $12 million grant that was given to our health system to really begin the process of integrating primary care and behavioral health services under one roof and instituting universal behavioral health screening in our primary care clinics. Prior to that time, we had a few behavioral health professionals across our system that were in primary care clinics. But by and large, prior to that grant, most of our behavioral health workforce were working in specialty mental health clinics. As a result of that grant, we began to hire what we now call integrated health therapists that are licensed mental health professionals who are embedded in primary care clinics… so, family medicine, internal medicine, pediatrics, OB/GYN. When the grant ended in 2015, our leadership at the time said going forward, this is how we’re going to do business because we’d had such wonderful results from the initiative. Today in 2020, we now have about 50 integrated health therapists in our system serving about 60 to 65 primary care clinics, either in-person or in some cases using telehealth platforms.

Host: What are the benefits of having these embedded therapists in these primary care settings?

Dr. Leichter: That’s a great question, Courtney, thank you for asking that. So integrated behavioral health is something that actually is happening all over the country. Sanford is certainly a leader in that, but a lot of research has been done looking at what really is an added positive for having integrated health. So, a number of things have been demonstrated. One is that when we have mental health counselors in our primary care clinics, it really reduces the stigma for patients who may need to visit with a behavioral health professional. They can come to the clinic. We kind of think of it as a one-stop shop for all your health care. So whether you need medical care or you need mental health care, it all happens under one roof. And so for many patients, it reduces that stigma. We also know that a lot of problems when they’re identified earlier on in primary care, before they become much more serious problems can actually help with access to specialty mental health care. In other words, some of those patients who previously might have been unidentified as having a behavioral health problem and that problem got worse and worse and then they tried to access our mental health system where access is just very, very challenging. So we’re able to hit some of the problems upstream, where it’s a little bit easier to treat.

Learn more: Behavioral health at Sanford

We also noticed in our in our CMS grant, and we’ve noticed since, that the detection of problems like depression and anxiety and suicide have gone way up now that we have professionals under the roof there that are equipped and educated to handle that. So we’re much more adept at being able to identify patients with those serious problems and treat them earlier on. We also hear from our primary care doctors that they have tremendous satisfaction with this. In fact, one of the comments we like to share anecdotally is we’ve had some physicians say don’t ever get rid of my IHT or I’m not going to be here either. Because in the past, when a patient would come in with a complex psychological problem, it oftentimes made it very difficult for that physician to be able to handle that problem in a short period of time. And then lastly we know that the cost of caring for patients who have comorbid behavioral health problems along with diabetes or hypertension, or asthma is three-to-four times higher when we don’t treat that underlying behavioral health problem. It’s good for the health care system in general because it saves money, our staff feel better equipped to handle those problems and patients in surveys have told us that the one person that they trust the most to talk about their behavioral health problem – outside of their family – is their primary care doctor.

Host: At what point did you realize that this would be something that we needed in the clinics?

Dr. Leichter: The real bulk of the program started in 2012. Prior to that there were a few behavioral health professionals was one of them. I was up in the Detroit Lakes Clinic and had been since 1990, but that was very odd, almost all of our workforce were working in very traditional mental health clinics within Sanford. And it’s not that there haven’t been behavioral health problems all this time, but the old fashioned way of doing this is that you might go into your primary care doctor and he or she might have a conversation with you about maybe needing some help for some anxiety or some family problems or some depression. And they would often hand you a card and say, here’s a referral to our behavioral health clinic. It’s three weeks from now or four weeks or six weeks. And we know that nationally only about 50% of appointments are made when a referral is given to a behavioral health clinic. So, half the time patients don’t show up for any number of reasons. Once we started putting our integrated health therapists into primary care, it became evident very quickly that we could handle that huge need really right away. And that’s one of the things that is really unique about IHT is that they don’t have a scheduled appointment every hour like we would see in a typical behavioral health clinic. We try to have at least a good chunk of their, of their daily schedule be wide open so that when a patient comes in and is identified as having a mental health concern, we can have that IHT step into the room right now, before you even leave the clinic we call that a warm handoff where the physician will go and get the IHT and bring that person into the room and say, Courtney, this is Jeff. Jeff’s our IHT. He works with us here in the clinic. I’m going to have him talk to you about what you and I discussed a little bit ago and then he’s going to circle back with me and we’re going to make sure that we collaborate on providing the best care possible. So, it was almost like there was a vacuum. The need was always there, but the, the resource frequently was not. So, it has been a huge success.

Host: And it sounds like you’re hearing some great feedback from providers and clinicians, physicians in those clinics. Is that right?

Dr. Leichter:  Yeah, that’s absolutely true. For some of the clinics that have had IHTs now, since the program started, which was now eight years ago, it’s just become part of the fabric of that clinic. And when that IHT is gone on vacation or maybe goes out on medical leave for whatever reason the physicians say, ‘Hey, who’s gonna, who’s gonna step up and do this for us?’ because they’ve come to rely upon this so heavily. There’s lot of research out there about what percentage of problems that are brought into primary care really are problems that have some kind of psychosocial component underneath. And depending on which research you read, it would seem that it’s much more than 50%, that there’s not just kind of a straight diabetes patient or a straight hypertension patient. Everybody is coming in with variables in their life that’s making those problems harder to take care of. So that might be problems at home. It might be financial stress, it might be parenting stress. Maybe there’s some trauma from that patient’s lifetime that makes it hard for them to adhere to the treatment that their doctor is trying to give them. So, yeah, we have heard all kinds of positive things from primary care that they’re able to hand off these complex patients. The other thing we’ve heard is that, by having an IHT in the clinic, the behavioral health knowledge of the entire team is raised by having that subject matter expert there. There was a lot of informal education that goes on with the rest of the medical team about how these social factors impact their health.

Host: And as a clinical psychologist yourself, how proud are you that Sanford has built a program like this to include, like you said, more than 50 integrated health therapists across the footprint?

Dr. Leichter: I am extremely proud. When I started with, with Sanford – Merit Care up in Detroit lakes back in 1990 when I was being recruited and I remember very distinctly, I flew into Fargo and they were driving me from Fargo to Detroit Lakes, Minnesota. The individual at the time said, you know, this is just an experiment referring to putting me into a primary care clinic. And he said, you know, it’s probably not going to work. It’s probably not going to take off. And you’ll end up working here in the behavioral health clinic in Fargo that was 30 years ago. And it was an experiment, but it did take off and I have so much gratitude for really Sanford’s willingness to look at a very different treatment model that embeds behavioral health alongside primary care across our country and across healthcare in general for so long behavioral health has been what we call carved out. It’s been forced to exist in a different silo, kind of often the shadows somewhere, but Sanford has shown great foresight in seeing that behavioral health is just simply health and it needs to be brought out of the shadows and treated like any other health problems. So I’m not only extremely proud of the program, I’m really grateful to Sanford for being willing to really go down the road with this.

Host: This is going to be a two-part episode and we’re going to actually talk to one of those integrated health therapists, Chelsea Christensen, who is at a clinic in Bismarck. I’m really looking forward to that. Now, do all regions have an integrated health therapist like Chelsea, or are there plans to continue growing that for all of the clinics in the Sanford footprint?

Dr. Leichter: We are always in recruitment mode looking to add IHTs to clinics where we don’t have them. Some of the clinics are very remote and very small, and they may not be able to support an onsite IHT full-time. So we we’re trying to build our tele-health efforts into those clinics where we’ll have an IHT doing exactly what I’ve described, but, but doing it virtually from a larger clinic, as far as our distribution we do have IHCs in all four regions. Fargo and Sioux falls are the largest, but we also have IHTs in primary care in Bemidji and in Bismarck, and then scattered throughout our network as well. So we do have a presence in all four of our hubs. We just saw an IHT hired in Thief River Falls as well, so that it was their first IHT. So all of our regional hubs have at least one, and in some cases more than a dozen, I believe in Sioux falls. But then we also have them scattered around the region like Watertown and Chamberlain and throughout the network even though they’re not, not in an immediately large hub. It is growing, we’ve had great feedback and you know, hopefully we will continue to expand as the need gets greater and greater. And certainly during this pandemic, we’re seeing huge increases in the demand for behavioral health services.

Host: Yeah, that was my other question. How does the COVID-19 pandemic impact these services?

Dr. Leichter: The Centers for Disease Control (CDC) just released some data within the last month or two looking at a snapshot of the mental health of adults in the United States. And it is particularly concerning depression and anxiety are up about 300 to 400% from this time last year. It’s particularly concerning that in the survey of approximately 11% of adults in the United States said that they had seriously considered suicide in the last 30 days. And what we’re seeing in reports from our integrated health therapist is that the demand for services in the last six months has grown exponentially for reasons that I think we all understand. People are under tremendous pressure economically, occupationally, at home trying to juggle parenting and being their children’s ad hoc teachers if their kids aren’t in school. So, we’re going through a very tough time in this country with regard to mental health. And it has shown that our IHT is busting at the seams, so to speak, in terms of requests for services.

Host: On that note, if in fact somebody is listening in and they’re struggling from anxiety, depression, and they just need to talk to somebody, how would they go about setting up an appointment? Why don’t you explain the process to me.

Dr. Leichter: Yeah. So you’re absolutely right. The way the model is set up is that we really want folks who believe they may be struggling with these kinds of problems to go to their primary care provider first. So that might be their physician or their advanced practice provider and to just schedule an appointment and go in. And what we find is that sometimes these problems have both psychological and physical components. So we want to make sure that people are medically healthy that they’re not struggling with something that can be easily corrected by an intervention from the family physician, but the case where it appears that they may need to see an IHT,  the IHT is available in real-time in, like I said, about 65 of our clinics. And so we really want the family doctor or the primary care provider to be the first point of contact as they should be with any kind of a health concern. And, you know, folks just need to be really, really honest. We put a lot of emphasis on trying to really portray behavioral health care as being no different than coming in and getting weighed or getting your blood pressure taken or getting a lab test. It’s a serious health concern. It needs to be talked about, start with your primary care provider. We talk about primary care being kind of the super highway of all health care and that includes behavioral health care.

Host: What else would you want our communities to know about the care that they can expect at Sanford through this program?

Dr. Leichter: I want people to understand that when they come in to talk with their primary care provider or ultimately an IHT – or any behavioral health provider in our system – that they’ll be treated with respect and with dignity. We understand that this is not a weakness that’s just going to go away if you pull yourself up by your bootstraps. Unfortunately, you know, one of the things about stigma and in the upper Midwest is that you kind of keep your problems to yourself and you just keep on going that oftentimes does not work out so well when you have a mental health problem, which can be progressive and it can get worse and it can impact your overall health care. So I want people to know there’ll be treated with dignity, with respect. We will take it seriously. We will hook you up with – if not an IHT – than another behavioral health professional within our system. We have a very dedicated behavioral health workforce that is very strong. We use evidence-based practices. You will find a no-judgment, only solutions. So please don’t hesitate to come in, talk with somebody. One of my favorite pieces of advice to give to everyone is never worry alone. If you’re worried that you might be struggling with something, don’t keep that in your own head. Don’t worry alone, go to your doctor, and we’ll take care of you from there.

Host: Dr. Jeffrey Leicther, I appreciate your expertise and all that you do here at Sanford.

Dr. Leichter: Thank you, Courtney. Thanks for helping to get the word out about this, the importance of behavioral health. Really appreciate your support, as well.

Host: This was another episode of the Health and Wellness Podcast series by Sanford Health. I’m Courtney Collen, thanks for being here.

Posted In Behavioral Health, Family Medicine

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