Primary Care and Behavioral Health in the Age of COVID-19 — How Social Workers Can Help Preserve the Patient Relationship
By Lauren Dennelly, MSW, LCSW
Social Work Today
Vol. 20 No. 4 P. 24

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
To say that today’s modern-day primary care experience is changing may be an understatement. To be fair, this experience has been changing in the years prior to COVID-19 with the introduction of the Affordable Care Act of 2010, which left more people seeking treatment for issues in primary care settings for the first time. Post COVID-19, primary care providers (PCPs) can expect to see a surge in mental health concerns and ancillary psychosocial issues impacting overall health (Pfefferbaum & North, 2020). Overwhelmed by these new demands and with minimal training in behavioral health (a term that includes both mental health and substance use disorders), providers are finding themselves at odds with patients who are coming to them with multiple needs. Patients who are overwhelmed with stressors and let down by the failure of multiple large-scale systems are looking to providers for guidance. This tension between what providers have to offer and what patients seek threatens to undermine the already tenuous patient-provider relationship, which has been slowly eroding since the managed care era and is now pushed to its limits with the experience of a global pandemic.

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
The number of people who see their PCP rather than a psychiatrist for mental health care is increasing (Kroenke & Unutzer, 2017) and will likely continue to increase as PCPs see more patients who are uninsured and present with complex medical and behavioral conditions either generated or exacerbated by COVID. With more patients seeking treatment and poor access to specialty care, an explosion of behavioral health needs will cause PCPs’ patient loads to swell and expertise to be stretched to its limits. Additionally, social determinants of health (SDOH), defined by the World Health Organization (WHO) as “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (www.who.int/social_determinants/en) will continue to increase as a result of the pandemic. SDOH have been associated with poor primary care prevention outcomes, including poor chronic disease management (Katz et al., 2018) and existing research on SDOH and disasters tells us that the physical and psychological effects are long lasting beyond the initial crisis (Nomura et al., 2016).

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
Compounding these existing difficulties, the current global pandemic has placed an extraordinary burden on health care providers on the front lines of care. In light of this, the burnout potential of medical professionals has been highlighted both globally and nationally, most recently with the tragic news of a prominent emergency department physician in New York City who took her life after heroically caring for coronavirus patients. Prior to the pandemic, in 2019 WHO named burnout as an “occupational phenomenon” in the 11th revision of the International Classification of Diseases (ICD-11), the medical diagnostic system used by physicians worldwide to define and report diseases and health conditions, a significant step in recognizing the seriousness of the issue (WHO, 2019). Also in 2019, a report headed by the Harvard T.H. Chan School of Public Health reinforced the idea of physician burnout as a public health crisis, emphasizing the importance of addressing physician mental health in order to maintain the well-being of the public (Jha et al., 2019). Not only are PCPs burned out but some are leaving the field altogether, fueling a workforce shortage that is also influenced by a reduction in primary care incomes and declining interest in entering the field of adult primary care among medical students (Bodenheimer & Pham, 2010).

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
We know that the person you trust with your care matters. Whether you feel listened to, dismissed, understood, or alienated has an influence over whether or not you will continue to see a specific provider again. We also know that the health care relationship plays an important role in patient outcomes. For example, the expression of empathy, courtesy, friendliness, reassurance, and encouragement have all been found to be linked to patient satisfaction, compliance, comprehension, and the perception of a good interpersonal doctor-patient relationship (Beck, Daughtridge, & Sloan, 2002). Furthermore, patient experience variables, including patient satisfaction, are a consistent factor in how health care services are measured for reimbursement. How satisfied patients are with their care relies not only on such aspects of care including the experience of a particular hospital stay or the presence of a supportive companion during a medical visit (Jenkinson, Coulter, Bruster, Richards, & Chandola, 2002; Andrades, Kausar, & Ambreen, 2013) but also on relational components of experience including whether or not patients feel heard and respected. This has been defined in the literature in terms of perceived “responsiveness” of providers, or how patients feel they are treated when they interact with the health care system (Wolf, Niederhauser, Marshburn, & LaVela, 2014). WHO suggests that this responsiveness is important in “reducing the damage to one’s dignity and autonomy, and the fear and shame that sickness often brings with it” (WHO, 2000, p. 24). How well a health care provider’s responsiveness meets a patient’s expectations about feeling heard and respected may shape the patient’s interpretation of a provider’s behavior and intent. This can influence the patient’s interactions with the health care system as a whole, potentially predicting the likelihood of accessing care in the future.

Patients With Behavioral Health Needs
Patients with behavioral health needs in particular benefit from an empowerment-based, supportive approach, which requires the medical provider to relinquish the sense of control that is the default within medical paternalism in favor of helping the patient fit the treatment within their lifestyle (Blackwell, 1997). In fact, patients often prefer the PCP who provides a continuous relationship and a willingness to learn about patient behavioral health issues over specialty mental health expertise or consultation (Lester, Tritter, & Sorohan, 2005).

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
To the extent that we can imagine a post–COVID-19 world, there will be a point at which individuals will need to reassemble their lives into some kind of working order, both personally and professionally. In the medical community, to put it mildly, this is akin to coming out of a dark movie theater into the bright sunlight after watching a chilling psychological thriller. The mixture of disorientation, confusion, and a sense of unease lead us to ask: What just happened? How do I process this? How do I move forward with the knowledge that these things can and will continue to happen in our ever-changing world?

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.

References
Adams, D. R., Flores, A., Coltri, A., Meltzer, D. O., & Arora, V. M. (2015). A missed opportunity to improve patient satisfaction? Patient perceptions of inpatient communication with their primary care physician. American Journal of Medical Quality, 31(6), 568-576. doi: 10.1177/1062860615593339

Andrades, M., Kausar, S., & Ambreen, A. (2013). Role and influence of the patient’s companion in family medicine consultations: “The Patient’s Perspective.” Journal of Family Medicine and Primary Care, 2(3), 283.

Beck, R. S., Daughtridge, R., & Sloane, P. D. (2002). Physician-patient communication in the primary care office: A systematic review. The Journal of the American Board of Family Practice, 15(1), 25-38.

Blackwell, B. E. (1997). Treatment compliance and the therapeutic alliance. Harwood Academic Publishers.

Bodenheimer, T., & Sinsky, C. (2014). From triple to quadruple aim: Care of the patient requires care of the provider. Annals of Family Medicine, 12(6), 573-576. doi: 10.1370/afm.1713

Bodenheimer, T. & Pham, H. (2010). Primary care: Current problems and proposed solutions. Health Affairs, 29(5), 799-805.

Curtis, R., & Christian, E. (Eds.). (2012). Integrated care: Applying theory to practice. Taylor & Francis.

Dennelly, L. (2019). Navigating psychosocial challenges in primary care with an integrated behavioral health model. Clinical Social Work Journal, 47(3), 276-283.

Hasenecz, N. (2018, May/June). Trauma-informed primary care. Social Work Today, 18(3), 30-32.

Hinton, L., Franz, C., Reddy, G., Flores, Y., Kravitz, R., & Barker, J. (2007). Practice constraints, behavioral problems, and dementia care: Primary care physicians’ perspectives. Journal of General Internal Medicine, 22(11), 1487-1492.

Jenkinson, C., Coulter, A., Bruster, S., Richards, N., & Chandola, T. (2002). Patients’ experiences and satisfaction with health care: Results of a questionnaire study of specific aspects of care. Qual Saf Health Care, 11(4), 335-339.

Jha, A., Iliff, A., Chaoui, A., Defossez, S., Bombough, M., Miller, Y. (2019, January 17). A crisis in healthcare: A call to action on physician burnout. http://www.massmed.org/News-and-Publications/MMS-News-Releases/A-Crisis-in-Health-Care--A-Call-to-Action-on--Physician-Burnout/#.XE8ghFVKjb1.

Katz, A., Chateau, D., Enns, J. E., Valdivia, J., Taylor, C., Walld, R., & McCulloch, S. (2018). Association of the social determinants of health with quality of primary care. The Annals of Family Medicine, 16(3), 217-224.

Knaak, S., Mantler, E., & Szeto, A. (2017). Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions. Healthcare Management Forum, 30(2), 111-116.

Kroenke, K., & Unutzer, J. (2017). Closing the false divide: sustainable approaches to integrating mental health services into primary care. Journal of General Internal Medicine, 32(4), 404-410.

Lester, H., Tritter, J. Q., & Sorohan, H. (2005). Patients’ and health professionals’ views on primary care for people with serious mental illness: A focus group study. BMJ, 330(7500), 1122.

Luoma, J., Martin, C., & Pearson, J. (2002). Contact with mental health and primary care providers before suicide: A review of the evidence. American Journal of Psychiatry, 159(6), 909-916. doi: 10.1176/appi.ajp.159.6.909

Maslach, C., Jackson, S., & Leiter, M. (1996). Maslach burnout inventory manual. http://data.theeuropeanlibrary.org/BibliographicResource/3000043533501.

Miller-Matero, L. R., Khan, S., Thiem, R., DeHondt, T., Dubaybo, H., & Moore, D. (2019). Integrated primary care: Patient perceptions and the role of mental health stigma. Primary Health Care Research & Development, 20, e48. doi: 10.1017/S1463423618000403.

Nomura, S., Parsons, A. J., Hirabayashi, M., Kinoshita, R., Liao, Y., & Hodgson, S. (2016). Social determinants of mid-to long-term disaster impacts on health: A systematic review. International Journal of Disaster Risk Reduction, 16, 53-67.

Olayiwola, J. N., Willard-Grace, R., Dubé, K., Hessler, D., Shunk, R., Grumbach, K., & Gottlieb, L. (2018). Higher perceived clinic capacity to address patients’ social needs associated with lower burnout in primary care providers. Journal of Health Care for the Poor and Underserved, 29(1), 415-429.

Pfefferbaum, B., & North, C. S. (2020, April 13). Mental health and the Covid-19 pandemic. New England Journal of Medicine. doi: 10.1056/NEJMp2008017.

Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S., & Rajagopalan, C. (2015). Trauma informed care in medicine. Family & Community Health, 38(3), 216-226.

Telford, R., Hutchinson, A., Jones, R., Rix, S., & Howe, A. (2002). Obstacles to effective treatment of depression: A general practice perspective. Family Practice, 19(1), 45-52. doi: 10.1093/fampra/19.1.45

Wampole, D. M., & Bressi, S. K. (2019). Exploring strategies for promoting trauma-informed care and reducing burnout in acute care psychiatric nursing. Journal of Nursing Education and Practice, 9(5), 110-117.

Watkins, A., Rothfeld, M., Rashbaum, W., & Rosenthal, B. (2020, April 29). Top ER doctor who treated virus patients dies by suicide. The New York Times. https://www.nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html.

Wolf, J. A., Niederhauser, V., Marshburn, D., & LaVela, S. L. (2014). Defining the patient experience. Patient Experience Journal, 1(1), 7-19.

World Health Organization. (2019, May 28). Burn-out an “occupational phenomenon”: International Classification of Diseases. https://www.who.int/mental_health/evidence/burn-out/en/.

World Health Organization. (2000). The world health report 2000: Health systems: Improving performance.