It was poor patient access that prompted Cherokee Health Systems to begin integrating behavioral health specialists into their primary care clinics more than 2 decades ago.
“Patients were presenting to us with a spectrum of physical, psychological, and social issues, and access to behavioral health specialists in our area was very poor,” says Parinda Khatri, PhD, a clinical psychologist at the community health center in Knoxville, TN. The majority of their patients, she explains, would never initiate a visit to a behavioral health specialist on their own, and the few who did experienced lengthy delays.
By folding social workers, community health coordinators, psychologists, and psychiatrists into their primary care team, patients who would benefit from behavioral health intervention can now be promptly treated at the point of care.
Role of Primary Care
Behavioral health conditions are prevalent among adults in the United States. Indeed, 57% meet the diagnostic criteria for disorders related to anxiety, depression, impulse control, or substance abuse at some point during their lifetime, and 32% have met the criteria within the past 12 months, according to a 2011 report from the Kaiser Commission on Medicaid and the Uninsured.
Most Americans, however, receive no treatment for these or other disorders that impact their mental and emotional well-being, in part because they are never diagnosed. Behavioral health integration seeks to remedy that by bringing primary care clinicians and behavioral health specialists together in the same setting to facilitate better coordination.
Primary care settings are often the first (and only) safety net for patients with behavioral, mental, and emotional disorders. “There are a number of reasons that patients like to get behavioral health care in the primary care setting, but one of the most important is that there is still a stigma associated with behavioral health disorders,” says Russell Phillips, director of the Center for Primary Care at Harvard Medical School, which launched an initiative 2 years ago to integrate mental health expertise into 6 primary care practices. “The primary care setting is often an easier transition.”
Behavioral Health Integration
Behavioral health integration involves a total commitment to care coordination. “It’s not just mental health services provided in a primary care setting,” says Khatri. “It’s an alignment with the principals of primary care.”
At Cherokee Health Systems, she notes, behaviorists and primary care physicians share the same patient panel, collaborate on a daily basis, and work together to design and implement a patient care plan. “By embedding behaviorists as part of the primary care team, there’s cross-fertilization of knowledge and an increased mindfulness and attention to these issues,” says Khatri.
Under the most widely tested models, primary care clinicians are trained to use evidence-based practices to screen for and treat the most common conditions, including depression, substance abuse, and anxiety, according to the Commonwealth Fund, a private foundation that promotes a high-performing health care system. The in-house case manager or behaviorist then follows up with patients to monitor their response and adherence to treatment.
However, not all practices can afford to retain dedicated behavioral health specialists. Some of the smaller practices participating in the Harvard initiative have successfully used telemedicine to facilitate both provider-to-provider and provider-to-patient consultations, says Phillips.
To ensure sustainability, practices must prioritize integrated care goals, revamp workflow, and overhaul their infrastructure, including administrative policies, credentialing, and confidentiality agreements, according to the federal Center for Integrated Health Solutions (CIHS).
Technology upgrades are vital as well. Practices can use a certified electronic health record system that offers shared records. CIHS says the behavioral health clinician’s assessment, plan, and documentation of progress need to be easily accessible by the primary care clinician, who is co-treating the patient and, in some cases, may be implementing and supporting behavioral health recommendations.
At the same time, CIHS suggests that providers who hire behavioral health specialists must be prepared to measure outcomes and quality of care, generate health registries to monitor care for chronic illness, track health care industrywide standards electronically, and, ideally, generate and share a coordination-of-care document that includes both primary health and behavioral health information.
Many private payers still use separate provider networks, as well as billing and coding practices, for primary care clinicians and behavioral health specialists. “Reimbursement for integration has been very piecemeal,” says Laura Galbreath, CIHS director. “Practices have had to tap the available resources they have and be creative.”
Some private payers, for example, offer incentive payments for quality improvement that can help defray the cost of integration, and many health care foundations support qualified early adopters via grants. Practices can also explore their state’s billing policies and Medicaid plan to identify which services they can bill for using health and behavioral intervention codes.
Going forward, the cost of integration may be less of a burden to bear as payers shift from volume- to value-based reimbursement, says Galbreath. Global payment models, in which providers receive a fixed monthly or annual payment for the care of a patient, could enable behavioral health integration in the primary care setting to thrive.
Reimbursement potential, however, should not be the main motivation for behavioral health integration. “All too often the first question we hear is, ‘How am I going to pay for this?’ vs understanding that, if you really want to improve care, doing good behavioral health will improve outcomes and the care that patients receive,” says Galbreath.