Pilot Project Integrates Primary Care and Behavioral Health Services

Collaborative care model offers benefits to patients and providers


Recognizing a need to bridge the traditional gap between primary care and behavioral health care, Duke launched the Duke Outpatient Clinic (DOC) Behavioral Health Integration pilot in 2016. The project brought behavioral health consultants (BHCs) into the clinic to provide counseling and support to patients who might otherwise be unwilling or unable to access these services.

Survey results from the pilot indicate a high level of patient and provider satisfaction and demonstrate an important step toward improved access to behavioral health services and whole-patient care.

“In primary care we’ve known for a long time that many patients are dealing with a variety of mental health disorders that come to the surface when we’re handling other aspects of their care,” says Patrick Hemming, MD, MPH, a Duke internal medicine physician who helped lead the project. “Often, these issues are at the heart of what a patient is seeking help for.”

During the two-year pilot, two BHCs joined the DOC to assist with coordination of care, counseling, and support for patients with a wide variety of behavioral health conditions, ranging from anxiety to severe, persistent mental illness. Services frequently involved meeting with members of a patient’s family to assist with complex interpersonal challenges.

In the first year of the pilot, more than 3,000 DOC patients completed routine screening for behavioral health conditions. Patients were asked about depression, anxiety, substance use, memory concerns, and social determinants of health, such as lack of access to housing, food, and medications. More than 25 percent of the patients who were screened had a mental health or substance abuse concern.

The BHCs worked with more than 1,000 patients in the first year of the project, including patients referred following a positive screening and patients referred by providers based on concerns raised during a primary care visit.

Post-services surveys showed a high level of patient satisfaction and gratitude for the time and attention received for conditions that affected patients’ overall health. “More than half of the patients reported that they wouldn’t otherwise have sought behavioral health services,” says Hemming. He adds that access to behavioral health services can be difficult for many people who live in smaller towns and counties that don’t have a significant specialty medical environment, but the integrative model of care can help smaller practices link patients to hard-to-find resources.

Hemming says that historically federal and state policies have treated medical care and behavioral health care as separate endeavors, with different regulations and payment structures. This legacy has made it difficult for practices to support integration of behavioral health services into primary care; however, several factors are beginning to bridge some of the false divisions that have made integration so rare. Hemming highlights three major developments that are opening new doors:                

  • A growing number of trials demonstrate effectiveness in delivering evidence-based care with improved outcomes for primary care patients with common behavioral health conditions. 
  • Insurers are beginning to reimburse for primary care collaborative care management services. Medicare has adopted new billing codes for BHCs to provide counseling and support. Several states are adopting new Medicaid initiatives to allow payment for integrated services.
  • The movement toward value-based care through relatively low-cost interventions, such as the collaborative care model, is decreasing the use of more costly interventions, such as emergency department and inpatient hospital care.

Hemming suggests that another benefit to integration is physician satisfaction and well-being. “The area of behavioral health presents physicians with some of their more difficult-to-solve problems,” he says. “It’s a relief when there’s some extra help with finding resources for patients and following up with them. Physicians are glad to see their patients receive the extended help they need and get better.”

The pilot ended temporarily in March 2018, but efforts are ongoing to build a permanent and sustainable program based on results and lessons learned.