Integrating Behavioral Health and Primary Care

INTEGRATING CARE FOR mental, behavioral and psychosocial issues into primary care has become increasingly important in recent years. From depression, eating disorders and anxiety to substance abuse, nearly one in five Americans has been diagnosed with some type of behavioral health condition, leading to healthcare costs estimated as high as $57 billion a year, on par with cancer.¹ In fact, the innate connection between mental and physical health is well-documented; while many patients come to primary care seeking relief for physical symptoms, those symptoms often have their root in mental or behavioral problems. Inversely, chronic illness can lead to depression, stress or other behavioral health challenges. The complexity of these issues results in myriad obstacles for the primary care provider, while also impacting patient outcomes and healthcare costs.

“If we are going to look to develop a high-performing healthcare system that deals with the totality of medical costs, ignoring mental health and substance use as drivers of costs and human suffering will not work. These illnesses are too big to ignore and too important,” says Paul Summergrad, MD, past president of the American Psychiatric Association.²

Assessing Current Integration Models

The concept of integrating primary care and behavioral health is not new. Some of the most successful care models focus on training primary care providers to use evidence-based practices in screening for depression, anxiety and other conditions that can be effectively managed in primary care settings. These models often incorporate a care manager or behavioral health specialist who follows up with patients and monitors their response and adherence to treatment. The main goal of most integrated care programs is to improve communication between behavioral health and primary care providers and thereby improve care coordination.

Two of the best-known approaches, the Collaborative Care and TEAMcare models, were developed at the University of Washington.³ A key aspect of the Collaborative Care model is the strategic use of psychiatrists who are tasked with providing consultations to primary care providers, with a focus on patients who don’t make progress or who have more serious mental illnesses.

Collaborative Care focuses on defined patient populations tracked in a registry, measurement-based practice and treatment to target. Trained primary care providers and embedded behavioral health professionals provide evidence-based medication or psychosocial treatments, supported by regular psychiatric case consultation and treatment adjustment for patients who are not improving as expected. The approach originated in a research culture and has now been tested in more than 80 randomized controlled trials in the U.S. and abroad. Several recent meta-analyses suggest that Collaborative Care consistently leads to better patient outcomes, better patient and provider satisfaction, improved functioning and reductions in healthcare costs.⁴

TEAMcare, another approach that is rapidly attracting interest, offers the simultaneous treatment of mental conditions such as depression and medical conditions such as diabetes using teams of behavioral health and primary care providers. The model is designed to prevent situations in which one poorly controlled chronic condition lessens the effective treatment of another.³ According to the National Institute of Mental Health (NIMH), this model provides significant benefits: “Addressing the whole person and his or her physical and behavioral health is essential for positive health outcomes and cost-effective care. Many people may not have access to mental healthcare or may prefer to visit their primary healthcare provider. Although most primary care providers can treat mental disorders, particularly through medication, that may not be enough for some patients.”³ And, says NIMH, historically, it has been difficult for primary care providers to offer effective, high-quality mental healthcare when working alone. Supporting these providers with mental health services and expertise has the potential to reduce costs, increase quality of care and, ultimately, save lives.

Counting the Costs

Despite efforts to create successful integrative care models, widespread behavioral health integration is still rare, and the integration of substance abuse services is even rarer. Lack of integration is due, in part, to little or no financial incentive or administrative advantage to bringing what are now stand-alone medical and behavioral health operations together. Payers use separate provider networks, billing and coding practices, accreditation metrics and record-keeping requirements. This makes a team-based approach to care difficult to finance and structure — whether it’s achieved by including behavioral health professionals in primary care settings or medical practitioners in behavioral health settings. Primary care practices that seek to enhance behavioral health services face restrictions on the types of services for which they can bill, and reimbursement rates are often low. And, sometimes there are pre-approval requirements or other restrictions that make it difficult for behavioral healthcare providers to work side-by-side with primary care clinicians.⁵

“Payment is the heart of the problem,” says Roger Kathol, MD, president of Cartesian Solutions Inc., a Burnsville, Minn.–based consulting firm that advises health systems, health plans and other purchasers on sustainable strategies for integrating behavioral health and physical health services. Benjamin Miller, PsyD, director of the Eugene S. Farley, Jr. Health Policy Center at the University of Colorado School of Medicine, agrees: “Healthcare as a system has not evolved to align financial mechanisms, practice delivery, training and education, and even our community expectation, to support a model of care that integrates behavioral health.”²

To address these concerns, some organizations are testing whether a global payment model can support the provision of behavioral services in local primary care practices. In 2012, the Colorado-based Rocky Mountain Health Plans — in partnership with the family medicine department at the University of Colorado, Denver, and the Collaborative Family Healthcare Association, a nonprofit that promotes collaborative models of primary care — launched a pilot titled SHAPE (Sustaining Healthcare Across integrated Primary care Efforts). In the pilot, three practices in Western Colorado that have already integrated behavioral healthcare are receiving global payments to fund team-based care, with three integrated practices that earn fee-for-service payments serving as controls.²

Under the pilot guidelines, instead of offering supplementary per-member/per-month payments to reimburse practices for delivering behavioral healthcare, as some insurers have done, SHAPE’s leaders opt for a global payment approach to reimburse practices for the full costs of providing behavioral healthcare — taking into account staffing resources and the number and complexity of patients served. The global payment also provides practices with flexibility to determine which services will produce the best results, as well as to dedicate time to panel management, care coordination and other “in-between-visit” activities that may lead to big health gains. “We don’t want behavioral health providers to be trapped by requirements to demonstrate productivity by the volume of traditional mental health services they render or to earn their ‘keep’ through a fee-for-service revenue model,” says Patrick Gordon, associate vice president at Rocky Mountain Health Plans. “We think that pulls them away from the care team, pulls them away from activity that might add value but can’t easily be coded.”²

Participating practices are held accountable for patients’ total costs of care: They stand to lose part of their payment if they do not meet certain budgetary and quality benchmarks, and they can also earn incentive payments for demonstrating improvement in health outcomes. The long-term goal is “to show what’s possible when you can actually create a global budget,” Gordon adds. “You can allocate resources to create value, and set up aligned gain-sharing mechanisms. It’s accountability and gain-sharing mechanisms that pull people together.”²

Incorporating Electronic Health Record (EHR) Technology

Of the many stakeholders in the discussions surrounding behavioral health and primary care integration, the role of healthcare information technology (IT) can be significant. Health IT tools ranging from shared electronic medical records to patient registries can be utilized to facilitate the integration of behavioral health into primary care. When used effectively, health IT helps providers communicate and can promote systematic screenings through clinical decision support mechanisms.

EHR technology plays a pivotal role in bringing behavioral and medical teams into closer collaboration. An EHR that successfully connects primary care physicians, behavioral health providers and care coordinators can ensure all parties are in sync, working to develop a patient-focused, holistic plan of care. One of the challenges historically has been the methods used for sharing vital information commonly depended on traditional mail and fax services. To reinvent the care model, automated IT is key to successfully integrating the behavioral and medical disciplines for enhanced collaborative care. By utilizing EHR technology, behavioral health and primary care providers can help bring the two worlds closer and foster a new spirit of teamwork.⁶

In addition to improving communication, an EHR that fully integrates behavioral and medical health modules can help eliminate redundant testing and reduce the risk of contraindicated care. It’s important to keep in mind that while many EHR systems are adept at meeting the needs of hospitals and medical specialties, they may be less familiar with the unique needs of behavioral health providers. For example, behavioral healthcare often requires more repeat visits than primary care. It is not unusual for a patient who sees a primary care doctor twice a year to see a behavioral health therapist weekly. In addition, documentation requirements are distinctly different, as are coding issues. The ICD-10 diagnosis codes used by medical providers give way to DSM-5 in behavioral health.

A 2017 study published in the Journal of the American Board of Family Medicine states that as integrated primary care and behavioral healthcare services come to the forefront, healthcare organization leaders must establish strong EHR use to enable better care coordination between the two specialties. The study’s research team conducted feedback interviews with¹¹ Colorado-based primary care practices integrating behavioral health into their workflows. Following a three-year test period and retrospective qualitative interviews, the researchers identified five common themes to effective care, with one of those themes the need to use targeted data collection pertinent to integrated care to drive improvement and impart accountability.⁷

Specifically, the research team found strong EHR use was critical to care coordination between patients and primary care and behavioral health providers. Creating a substantial health IT infrastructure was among one of the primary suggestions between each of the participating healthcare organizations. “Establish standard processes and infrastructure necessary for your integrated care approach: workflows, protocols for scheduling and staffing, documentation procedures and an integrated EHR,” the researchers said, citing one of the common recommendations for integrated primary and behavioral healthcare.⁷

As healthcare organizations move toward collaborative care to combat behavioral/medical comorbidity, EHR technology can play a vital role. However, harnessing the full power of this technology requires a new mind-set by recognizing all providers need equal input and access to patient records. To accomplish this, health professionals must work together and learn to rely on the power of instant communication instead of sending notes via mail or fax. With that in mind, the study concluded an integrated EHR platform can be a powerful ally in uniting behavioral and medical providers to better meet the complex needs of multi-condition patients.

A Worthwhile Pursuit

The idea of a practice model that successfully integrates behavioral and primary care is a topic worthy of further discussion. Forward-thinking primary care practices that successfully implement collaborative care for depression and other chronic mental health disorders are shown to report much higher rates of remission and recovery. Readily available and predictable crisis management services for distressed patients, whether by full integration, colocation or via agreement with community-based behavioral health service providers, can give patients timely access to mental health expertise and provide relief for busy primary care teams. While numerous collaborative care obstacles still exist, the benefits to both patient and provider make this innovative healthcare model a worthwhile pursuit in our evolving healthcare landscape.