Integrating behavioral health into end-of-life care

By Lisa King, PsyD


According to the National Institute of Mental Health (NIMH) approximately 20 percent of the US population experiences symptoms of mental illness (mild to severe in nature). Around five percent of the US population suffer from a severe mental illness which is defined as “a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.”

There are multiple risks associated with mental illness including, but not limited to, co-occurring substance use disorders, chronic disease and increased suicide risk. Walker, McGee, and Druss published an article where they looked at the mortality associated with mental illness. By analyzing 203 studies, they found that for those with mental illness there is an average reduction in life expectancy of 10 years (ranging anywhere from 1 to 32 years). Sixty seven percent of this early mortality was attributed to natural causes and 17.5 percent of the deaths were attributed to unnatural causes.

Individuals with mild to severe mental illness are being treated in Hospice and Palliative Care settings across the nation. Some experience depression or anxiety because of their physical health problems. Others have life-long mental illness that impacts their ability to function on a day-to-day basis. These patients may need additional support to understand, to cope with and to make informed decisions about end-of-life care. Likewise, Hospice and Palliative Care providers are attending to the physical needs of patients whose mental health needs may interfere with their ability to comply with treatment recommendations.

Hospice and Palliative Care teams are interdisciplinary, often including MDs, ARNPs, RNs, CNAs, social workers, and chaplains. While many social workers are trained in mental health diagnosis and treatment, they are often tasked with connecting patients and families to much needed resources. Most carry large caseloads and though they provide psychoeducation and in-the-moment support, they often are not free to provide ongoing psychotherapy.

Bluegrass Care Navigators recognized the importance of integrating behavioral medicine into their service lines. They understood that there is a need to support patients and families who have chronic and life-threatening physical and mental health issues. Because of this insight, we are developing a program that educates, informs, and provides direct care to patients and families facing life-limiting illnesses.


The road to integrating mental health treatment into any healthcare system is difficult. There are internal and external obstacles ranging from buy-in to sustainability. We began by supporting clinicians and administrators. By improving the coping and resilience of our frontline workers and administrative staff, we hoped to decrease burnout and turnover which disrupts delivery of care. We also began providing consultation to the various Hospice and Palliative Care teams to inform and educate clinicians on mental health issues.

Externally, we have partnered with other agencies to provide psychoeducation and support to the community. By providing opportunities to discuss mental illness we hope to decrease the stigma and encourage providers, patients, caregivers and family to seek help as needed.

The pandemic has advanced the provision of mental healthcare in Kentucky. The emergency orders to allow and reimburse telehealth is the silver lining of this very trying time. Most of Kentucky is considered Federally Underserved with regards to Mental Health. This means that our most vulnerable patients must look outside their own communities for mental healthcare.

Prior to the pandemic telehealth for mental health was not available to most of Kentucky’s citizens. However, patients now can seek care from their homes if they are unable to travel due to health status, financial constraints or lack of transportation. Telehealth for mental health has opened doors at Bluegrass Care Navigators as we have been able to offer support to caregivers, provide individual/family therapy, and collaborate care for our pediatric patients (e.g., meeting with primary care, specialists, and schools).

As we expand our mental health program at Bluegrass Care Navigators, we hope to develop talent from within our own ranks who are trained in mental health or substance use disorders. This initiative would empower clinicians who are already trained in mental health service provision to utilize the skills, techniques, and interventions with which they are already equipped. Ideally, each county we serve would have at least one member who is prepared to help their team effectively treat those with complex mental health issues.

University Partnerships

There are few (if any) psychology graduate programs that incorporate training in Hospice and Palliative Care. Most individuals are left to gather this knowledge through self-guided reading and continuing education. Bluegrass Care Navigators is working with local universities to provide a practicum for graduate level psychology students to introduce them to end-of-life care. By partnering with future mental health clinicians, we hope that behavioral medicine programs within Hospice and Palliative care will become the rule, not the exception.

-Lisa King, PsyD, is a licensed psychologist and the Director of Behavioral Medicine at Bluegrass Care Navigators in Lexington, Kentucky.