Early in my career, I applied for a job as a psychotherapist at a community mental health center that was located on the grounds of a county hospital. I was sent by mistake to the primary care health center, instead of the mental center to interview for a job.
The primary care center was full of people in starched white coats and was bustling with activity: people running all over and physicians giving orders. The lights were bright and harsh, and all the walls were white. The place looked very sterile, cold and antiseptic.
When I got to right place—the mental health center—it was calm and quiet by comparison, and the tempo was tremendously slower. The furniture was comfortable, and the lighting indirect. It looked less “scientific’ almost comfortably shabby. There was a palpable difference in atmosphere.
Examine the difference
Among the most frequently cited barriers to implementing integrated care are professional and cultural conflicts between primary care and behavioral healthcare (Larderi et al , 2014; Mauer, 2002). Mauer says such “clinical, structural and financial” differences must be taken into account in the development and implementation of any integrated care model.
Our organization’s integrated care program is just a year old. Six months ago, it became a Federally Qualified Health Center (FQHC), operating within the confines of a traditional community mental health center. The primary care component is housed and integrated with mental health, addictions treatment and psychiatric services.
To gather additional information regarding cultural conflicts, we conducted a voluntary online survey of staff. Thirty-six people responded, and 72.2% identified themselves as behavioral healthcare staff and 8.3% as primary care staff. Half of the respondents said that they had a lot of experience working in an integrated care setting.
One example of the cultural conflicts among the two groups of clinicians can be explained by simple vocabulary. For primary care, “MRO” means Medical Review Officer, but for behavioral healthcare staff, it means Medicaid Rehabilitation Option. Lardieri and colleagues observed that “MI” referred to myocardial infarction in the primary care sector, but means motivational interviewing to behavioral healthcare staff.
One respondent to our survey noted that behavioral healthcare staff spend more individual time with clients than primary care staff. Others said that behavioral health “views the client as a whole, while primary care seems to focus on the symptoms.” It was also observed that “primary care is more time-focused and those staff see more patients in a shorter amount of time.”
In regard to documentation, a primary care staff member noted that behavioral healthcare seems to have lengthier, more detailed notes. It has been said that in integrated care settings behavioral healthcare staff must learn to quickly describe a case to their primary care colleagues , instead of relying upon copious case notes (Lardieri, et al 2014). This more succinct approach (reflecting the limited time available to clinicians in primary care) may feel uncomfortable to behavioral providers. They might even perceive it as being clinically irresponsible, after being taught to value comprehensiveness and detailed documentation. Such values might stem from professional socialization within their discipline, identification with role models, or documentation requirements related to billing.