Primary Care and Behavioral Health in the Age of COVID-19 — How Social Workers Can Help Preserve the Patient Relationship
Picture yourself as a social worker in a once-bustling primary care office. The stay-at-home orders in your state have just barely been lifted, your temperature has been checked upon entering the building, you are masked, and it is your first Monday morning allowed back on site. The once-packed waiting room is now eerily empty, just a small handful of carefully spaced and equally masked patients sitting nervously, eyes moving from side to side. In a pre–COVID-19 world, this waiting room would be full of chattering patients, neighbors running into neighbors, strangers sharing ailments and remedies. Now, after multiple phone calls and patient portal messages to schedule COVID-19–safe well visits and other routine care, patients are fearful, coming into the office cautiously, and social distancing once they arrive. Front desk staff, once exhausted from managing large queues of sick patients, are now exhausted for different reasons, including constantly policing mask wearing and social distance protocols; sanitizing desks, tables, chairs, and anything people may have touched; and having endless conversations with people about how COVID-19 has touched their lives. Patients now present with “COVID-19 anxiety” as a visit reason, which encompasses the triple threat of potential illness, unemployment, and compounding mental health issues. Providers are working overtime to accommodate those patients who were unable to come in during quarantine and need to be seen. Additionally, with the cancellation of elective surgeries and a decrease in emergency department visits and inpatient admissions, the hospital system is experiencing sagging revenue streams, causing a general worry among staff about the possibility of furloughs and layoffs.
A Decade of Change
How are social workers positioned to assist in primary care amid this new reality, providing support to both the patient and the provider while bolstering their relationship with one another? To answer this question, we need to take a look at the trend of people seeking behavioral health treatment in primary care, the role of provider burnout, and why health care relationships matter, especially for patients with behavioral health needs. Finally, we’ll look at ways that social workers can help patients and providers strengthen these relationships, facilitating their connections to one another in an increasingly disconnected world.
More Patients, More Problems
Generally, psychosocial and unexplained somatic symptoms consume a disproportionate amount of the PCP’s visit time (Curtis & Christian, 2012). Many providers feel ill-equipped to manage patients with behavioral health needs, citing problems with access to specialty and community services, a lack of interdisciplinary care, time limits for visits, and patient complexity as barriers to providing quality care (Hinton et al., 2007; Telford, Hutchinson, Jones, Rix, & Howe, 2002). Additionally, patients who complete suicide have often visited their PCP within the last 30 days of completion, especially older adults, making primary care an integral part of crisis intervention for severely depressed patients (Luoma, Martin, & Pearson, 2002). The reality is that facing an increasingly stressed patient population, PCPs have to do more with less—less time, fewer resources, and less training—and the increased burden doesn’t only come from patient care demands. Increases in administrative demands related to the use of electronic medical records, including extensive time spent on documentation, is an oft-cited area of stress for PCPs (Bodenheimer & Sinsky, 2014).
Provider Burnout — A Public Health Crisis
Burnout can be defined as a “psychological symptom of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who work with other people in some capacity” (Maslach, Jackson, & Leiter, 1996, p. 192) and is a significant contributor to physician mental health. Taking care of people can be an emotionally draining job on the best of days, much less when the world feels turned upside down. Patients with behavioral health needs present unique challenges, including histories of trauma and difficulty with interpersonal interactions, that require a trauma-informed set of skills that many medical providers (and organizations) do not possess (Wampole & Bressi, 2019). Combine this complex patient population with already stressed medical providers and you have a perfect storm that threatens to undermine the foundation of the primary care working relationship. We need to take better care of our medical providers, especially those on the front lines who treat medically and behaviorally complex patients. Strong patient-provider relationships are an important contributing factor in keeping work meaningful and fulfilling and present a significant area of burnout prevention.
Why the Relationship Matters
Patients With Behavioral Health Needs
In addition, despite the fact that seeking behavioral health services in primary care is experienced as less stigmatizing by patients with these needs (Miller-Matero et al., 2019), stigma surrounding behavioral health issues continues to impact health care provision as a whole. People with mental illness experience poor access to care and poor-quality care, and often report feeling dismissed and dehumanized in their health care interactions (Knaak, Mantler, & Szeto, 2017). In addition, they are often faced with health care providers who have a negative view of recovery, which can act as a barrier to the recovery process (Knaak et al., 2017). Having a PCP who listens, is empathic, and follows up on a patient’s progress can have a hugely beneficial impact on whether or not the patient will discuss behavioral health concerns in a medical context in the future.
What Social Workers Can Do
Social workers, alongside PCPs, can help patients make sense of these questions together. The following are just a few important ways that social workers can help support PCPs in maintaining their relationships with patients who have behavioral health needs:
• Social workers can help PCPs deliver on their promise to address patient behavioral health needs by acting as trustworthy and knowledgeable specialists within the primary care office. Patients take provider referrals seriously, and they are more likely to go to someone their provider referred them to within the primary care office than to seek behavioral health treatment on their own (Miller-Matero et al., 2019).
• Social workers can also work individually or with team-based approaches to provide short-term treatment and ongoing care management or link patients to these resources in the community (Dennelly, 2019). The more patients feel that their needs are being met, the better this reflects on their provider’s decision to refer these patients to behavioral health support. Social workers in these settings act as an extension of provider knowledge, giving patients confidence that their PCP has the skills to help them and that they are treatable. A team-based, case management approach also helps address patient SDOH, which helps prevent the PCP from having to take the burden of this care alone, reducing provider burnout (Olayiwola et al., 2018).
• Social workers can translate and facilitate communication between the patient and their PCP, providing continuity of care, improving interactions and the flow of information, and helping the patient feel more listened, understood, and cared about. For example, continuity of care between inpatient and outpatient providers is important to patients, particularly vulnerable older adults, who often report more problems with communication with primary care after being discharged from the hospital (Adams, Flores, Coltri, Meltzer, & Arora, 2015).
• Finally, social workers can educate and support PCPs by filling in gaps in trauma-informed knowledge or skills and support them in feeling more empowered when approaching interactions with patients who have behavioral health needs. Trauma-informed care, or care that is provided with the knowledge of the effect trauma has on emotional and physical health, is especially important in medical settings. Providers can utilize trauma-informed knowledge as well as patient-centered communication, interprofessional collaboration, screening, and a heightened self-awareness to provide care that addresses the needs of people who have experienced trauma (Raja, Hasnain, Hoersch, Gove-Yin, & Rajagopalan, 2015).
In an ideal world, we would be able to return to the pre–COVID-19 waiting room experience right away, a community coming out of isolation to find solace and joy in the company of others. While this may not happen immediately, people are resilient and resourceful and have a genuine need for interaction that will drive them together again once fear subsides and the need for connectedness prevails. When this happens (and it will!), social workers will be there. Social workers have long been a part of medicine and can do important preventive work in primary care as advocates for patients and as supportive colleagues for medical providers. Social workers are well positioned to help medical providers preserve relationships with their most vulnerable patients, who will need even more support in a post–COVID-19 world. In a time when social connection is bound to deteriorate, social workers play a pivotal role in preserving health care relationships and mitigating burnout, thus helping strengthen the foundation of health care experience overall.
— Lauren Dennelly, MSW, LCSW, is a doctoral candidate and behavioral health specialist in integrated primary care in Lehigh Valley, PA. She is currently conducting research on the interpersonal dynamics underlying the patient-provider relationship in primary care with patients who have behavioral health needs.
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