March 4, 2026 Forum

I got very confused by that, and the solution to me was to integrate at the training level. When I came here to John Muir Health, that’s exactly what I have done. I will say it’s been a painful experience for me, probably one of the more humbling experiences as a leader—realizing that not all family doctors are going to think this is a great idea. Not all behavioral health people are going to think this is a great idea. However, the patients sure thought it was a great idea because a lot of them have gotten services through this integration. Probably anywhere from 10% to 15% of our visits now are behavioral health visits inside of our practice. That’s reflecting the fact that probably 30% to 50%, maybe 70% of our patients need it. Not all of them get seen by our therapists, SRD students, and supervisors, but this is still a substantial service. This was extraordinarily important for our practice during COVID when there were high levels of anxiety and suicidality going on. We would have had a great deal of difficulty handling that without the support that we got. We learned how to systematize the assessments and do this care. No matter how long I train, I cannot replace what a therapist can provide to our patients. It took a couple of years to come to an agreement; however, once this agreement was reached, I would say the bulk of the services they provided were warm handoffs. And warm handoffs are occurring basically nine half days a week. This is how many half days our residency practice is open, the other half day we have workshops. Our residents can immediately have a behavioral health person come in, see the patient, talk to them for 10 minutes, initiate a plan, oftentimes for short bursts of six to eight sessions over the course of the next couple months, and off they go. We have a near 100% show rate to that first visit because we basically bring them in the room right when we’re there. We finish up the visit. We had to go through complex discussions, should we get a different space for them, because the behavioral health providers said we need an hour, and I indicated that our clinic can’t afford anybody sitting there for an hour. That’s just not the way primary care is.

So, it was kind of culture shock for a lot of the therapists to see the enormity of the volume. They felt overwhelmed early on, and it took a lot of work trying to help them feel supported, that we needed them to do this. What they wanted to do was set up shop and do one hour visits for months to years. That was the model they were all trained in, and so we had to adapt and really be more flexible. They had to adapt and become more flexible. I’m thankful, for 10 years into this program, I can tell you that we have a very integrated high level called level six. I mean, we are fully integrated with our behavioral therapists.

They are now providing other neuropsych treatments and other kinds of testing, ADHD testing, all kinds of things that have really helped us a ton. We are billing for their services. During the first five years we were told it would cost us more to bill than we would actually get reimbursed. That’s been roughly true, but we were doing such a high volume of visits, we felt it was still necessary. So that’s a piece related to the complex part of the challenge. It’s understandable why somebody would want to say, let’s have an AI bot replace the behavioral health person so Dr. Fish can just connect somebody with a link right there, do a warm handoff to an AI bot.