Bolstering behavioral health programming in seriously ill populations could improve patient outcomes and have lasting impacts on care models and payment structures, according to research in the palliative care field. However, palliative care providers investing in behavioral health integration contend with challenges of specialized workforce shortages and a lack of understanding in psychosocial-specific care needs.

Mental health is among the many areas of serious illness care that providers are learning to navigate as they build their palliative care business lines. Improved access and deeper integration of psychiatric services stands to benefit the estimated 5 to 8 million older adults nationwide who have one or more mental health conditions. With complex medical and social needs, providing comprehensive and goal-concordant care will require providers to address behavioral health comorbidities in the palliative setting and beyond.

“Many people living with serious medical illnesses also suffer from comorbid behavioral health issues,” according to a recent report from the Center to Advance Palliative Care (CAPC). “Patients may be receiving some kind of behavioral health support, but even when available these interventions are time-limited or poorly aligned amidst myriad scenarios. Patients at the interface of behavioral health and serious illness care almost always require additional social services that go beyond the immediate clinical realm.”

Research published in the Journal of Pain and Symptom Management showed that seriously ill individuals with behavioral health problems face siloed care, high health care costs and poor outcomes, with limited interactions between physical and behavioral health providers among the contributing factors. According to authors of the research, behavioral health symptoms and syndromes are debilitating for patients, and can impact a range of serious illness outcomes.

“Patients with serious mental illnesses, like schizophrenia and bipolar disorder, have a particularly high need for models of integration that are able to accommodate their unique psychiatric and psychosocial needs,” the study’s five co-authors said in an email to Hospice News. “Patients with serious mental illness may have deficits in communication and reality testing and are prone to significant psychosocial difficulties including housing and food instability, as they are often victims of violence, isolation, and high rates of substance use. Beyond the suffering and symptom burden imposed by behavioral health complications of serious illness, these comorbidities also negatively affect a myriad of outcomes, including acute care service utilization, cost, management of non-behavioral symptoms (like pain), and mortality.”

The authors include Stephanie Cheung, Jon Levenson and Daniel Shalev of Columbia University Medical Center, and Harold A. Pincus and Brigitta Spaeth-Rublee of the New York State Psychiatric Institute.

Their study found that inadequate screening tools, payment mechanisms, workforce shortages and legal/privacy issues were barriers to behavioral health implementation in serious illness care. The research proposed a behavioral health/serious illness care model as a framework for integrating services tailored to palliative care populations and the range of settings in which they receive care. The model is intended to serve as a guide of best practices in serving those with behavioral health in any setting along the serious illness care continuum.

Having an interdisciplinary workforce of psychiatric professionals, clinicians, and trained social workers was among the key components to successful integration of the behavioral health serious illness care model.

Psychiatric training and education can help providers contending with industry-wide staff shortages. With workforce shortages also abounding in the behavioral health sector, combining forces to bring more diverse and expansive career paths could attract a wider talent pool in serious illness and end-of-life care.

“A well-actualized behavioral health palliative care team should have experts at the intersection of mental health and medical illness,” said the researchers in an email. “Ideally, psychiatrists who have medical and behavioral health backgrounds and comfortable managing a range of behavioral health conditions using pharmacologic and psychosocial interventions. Such expert clinicians could provide both direct patient care to patients with high behavioral health needs and also indirect consultation, supervision, and training to other clinicians on the palliative care team.”

While supporting an expanded workforce can increase operational spending, providers can implement basic behavioral screening practices as a more cost-effective strategy to evaluating unique psychiatric and psychosocial patient needs. With few validated screens currently in existence for the palliative care population, providers can incorporate mental health screenings such as the Hospital Anxiety and Depression Scale (HADS), or the Patient Health Questionnaire (PHQ-9) as a part of routine care practices, according to the authors.

“The use of more sophisticated, validated BH screens like the PHQ-9 for depression or the HADS for anxiety and depression as a part of routine palliative care practice would be an important first step in recognizing the needs of patients,” said the authors. “For patients with BH conditions other than anxiety and depression, integration of BH and palliative care is essential.”

To achieve widespread integration of serious illness care and behavioral health care, however, payers, including the U.S. Centers for Medicare & Medicaid Services (CMS) may need to re-examine some of the ways in which providers are reimbursed for palliative and serious illness care.

“Improving behavioral health provision in palliative care can run the gamut from small, individual-level changes in practice to systems-level changes in care structures and payment models,” the authors told Hospice News. “On the individual practitioner or clinic side, integrating validated BH screens for common conditions such as depression and anxiety into clinical workflow can improve detection of BH conditions and prompt appropriate management of referral. Collaboration with a psychiatrist through an integrated/collaborative care model, co-location, or even through a referral network can ensure that expert-level BH care is available to patients for whom provision of BH care through the typical palliative care treatment frame is insufficient. On the more system-wide level, creating models and payment structures for true integration of BH providers into outpatient, inpatient, and hospice palliative care teams is key.”