In order to improve communication about mental health issues and raise the quality of primary care, providers should consider taking their time with the patient and letting the patient guide the conversation, indicates a study published in the American Journal of Managed Care.
According to a research team led by Ming Tai-Seale, PhD, increasing primary care value is critical, with visits running the nation nearly $10 billion annually. While improving mental health discussions may not lower that figure, it could increase the value of these visits, making the spending more meaningful.
The researchers investigated mental health discussions for 484 patients in a Detroit-based integrated health delivery system. In a retrospective analysis of primary care visits, the researchers found that about one-third of visits included quality, evidence-based mental health discussions. Another third of patients had low-quality discussions, and one-third did not conduct a mental health discussion.
The research team then looked at the qualities that may have helped facilitate the evidence-based mental health discussion during primary care visits.
First, the team found that longer visits often resulted in evidence-based conversations that addressed the patient’s mental health needs and any potential ongoing mental health episodes.
“This finding echoes the observation that ‘slow medicine’ can be more appropriate for serving patients with chronic conditions,” Tai-Seale and colleagues wrote.
“It is also consistent with previous research that suggests visits in which physicians who provided appropriate counseling or screening took 2.6 to 4.2 minutes longer than visits in which patients did not receive these services.”
The researchers also found that providers who spoke less often and allowed patients to guide conversations yielded better interactions. The research team noted that physicians often like to drive the conversation in an effort to keep appointment times short. However, in order to facilitate an effective, patient-centered conversations, providers may consider relinquishing some control.
“Verbally dominant physicians disempower patients and impair patient engagement,” the research team explained.
“It has been well-documented that patients were less satisfied with their physicians when physicians talked more and when patients perceived their physicians as domineering, and patients were ultimately less likely to sue physicians with low verbal dominance.”
The third quality indicator was providers who picked up on patient cues and understood what the patient wanted to discuss during the visit. According to the researchers, patients often do not explicitly state their agenda at the start of the appointment. As a result, providers should carefully probe patients about their priorities during the visit and work their time around those issues.
Incorporating these behaviors into patient-centered workflows is easier said than done, Tai-Seale and colleagues acknowledged. Primary care physicians are often pressed for time, and extending conversations and expanding their interactions with patients may not be feasible.
Instead, some of the onus should be on healthcare policymakers.
“Policymakers should revisit the ongoing challenges of asking primary care physicians, who often are not trained in evidence-based counseling approaches, to deliver this care under increasing time pressures,” the researchers asserted.
“Improving the quality of [periodic health examinations] may require reimbursement for longer visits, training, and rewards that enable physicians to more fully elicit patients’ agendas and to listen more attentively.”
Additionally, other industry stakeholders should improve care coordination to support patients and primary care providers.
“We should consider means to offer support outside of the ambulatory encounters so that it is possible to extend the office visit conversation—that often falls short—beyond the visit so that it approaches recommended counseling content,” the researchers explained.
Improving mental health discussions in primary care is a vital component to improving value in that setting, the researchers concluded.
“Without significant improvement in the quality of PHEs, eliminating them may do more to improving value in healthcare for the nation,” Tai-Seale and colleagues said.