October 6, 2015 | Tags: Blog | Tags: Behavioral Health Integration , Mental Health , Care Coordination , PCBH
Behavioral health integration is an enormous part of successful patient-centered primary care. In 2013, there were an estimated 43.8 million adults aged 18 or older in the U.S. with a diagnosable mental illness or 18.5 percent of U.S. adults (National Institute of Mental Health [NIMH]). Integrating mental health professionals into primary care settings to help screen and treat those suffering from depression can aid in easing the debilitating mental, physical, and monetary cost to individual’s lives (Agency for Healthcare Research and Quality [AHRQ], 2012). Primary care is often the principal setting for providing behavioral health treatment, especially with depression, so it is imperative to consider whether the appropriate steps are being implemented to deliver such treatment (Croghan, & Brown, 2010). Behavioral health professionals working in coordination with primary care providers can help identify a larger number of persons who would benefit from treatment, administer the correct treatment, and better monitor those who are undergoing treatment. There are three main models of integrating behavioral health into primary care settings, and they each have pros and cons associated with them, but they all take steps to help reduce the fragmentation of health care.
The first of the models is coordinated behavioral health care. In coordinated care there are basic levels of collaboration between primary care and behavioral health providers. Providers are not in the same location, so routine screening for behavioral health problems are conducted in the primary care setting, and a referral relationship exists between the providers. There is a routine exchange of information to address the patient’s needs, and the patient is connected to other resources available in the community. This is a step above the typical referral as the patient’s needs are assessed in a primary care setting, and the providers both work to ensure that they meet those needs. This model is used by clinics that wish to provide better care for their patients, but are unable to afford to change the structure of their clinics, or may be in the process of working towards doing so. Because there can still be gaps in the referral process, this is not an ideal form of primary care integration, but it can address some of the issues that arise from non-coordinated care.
For co-located behavioral health care, providers are in the same location, but they do not usually work together during the same visits. This provides a closer level of collaboration between the providers. The primary care provider will assess the patient’s need for behavioral health care, and refer the patient to the on-site behavioral health provider. The two providers are also able to communicate more frequently about the needs of their patients. This provides a higher level of follow-through and lower level of “no-shows” for behavioral health patients. In order to look a little deeper into this form of behavioral health integration, I spoke to Christopher Tucker, a Portland based mental health care practitioner working for the past two years with Portland Integrated Health.
“Communication is always key, because you need to make sure that both the physician and the patient know what you’re doing and why you’re doing it. In my practice, the physician and I will work closely to determine the physical and mental health needs of our patients and then treat them appropriately. The physician will see the patient, and using SBIRT and other diagnostic tools, determine if the patient would benefit from mental health treatment. If so, the physician will make sure that the patient is scheduled for full visits as needed with me in order to address these needs. Oftentimes I assist in teaching patients skills to cope with their physical pain.
Clients are thrilled with the integrated approach. They get to do everything all in the same day, all in the same clinic. There are challenges, however. The major negative feedback we have received has to do with insurance company approval time for any referrals outside the clinic. I am also fortunate enough to be able to provide traditional therapy to treat my patients, and I do not have to do short incremental sessions. Although this shortened, integrated approach can be effective for teaching basic skills, especially in busy clinics where time is limited. If there is not enough time to do a full course of traditional therapy (including time intensive exposure therapy to help resolve trauma and obsessive compulsive disorders), it can be more effective to have the time to get to know your patient and really work with them, especially when it comes to attachment issues. Also if a facility is limited, clients with major addictions or personality disorders will be referred to outside clinics where they can receive more intensive treatment.”
The third model of behavioral health in primary care settings is full integration. This is the highest level of collaboration possible. The different services may be located in the same facility or accessed from a different location as needed, depending on the resources available to the clinic. There is typically one treatment plan with a prearranged protocol and a treatment team that works together to provide care. There is typically a database to track the progress of these patients. In order to look deeper at this model of behavioral health integration, I spoke to Lexy Kliewer, a licensed clinical social worker who has worked with LifeWorks Northwest for the past six years. She was able to clearly point out the benefits of full integration, as well as lay out advice for those clinics trying to work towards this model.
“In my experience the fully integrated model is better for the treatment of common behavioral health needs because it allows for the easiest patient access. Many times there is a lot of frustration that can arise from miscommunication in the non-integrated models. Full integration gets rid of the gaps by allowing the physical and mental health care of the patient be adequately addressed. This model is also very patient-centered, and it works to address short-term behavioral changes needed to better manage the patient’s health. Those who are in need of longer term or more in-depth behavioral health care are referred to an established network of outside providers we work with in the community, or they can choose to go where they would like.
There are some challenges with this model because Integration is still new. Payments and billing can be a hurdle to full integration. There is not a lot of clarity with documentation and coding, and this can be extremely difficult when a clinic is trying to get set up. Credentialing providers can also be difficult because providers need to be credentialed in primary care, not in mental health. Community communication really helps with these obstacles, however. There is the Integrated Behavioral Health Alliance of Oregon, which is a large group of health care professionals with different backgrounds that work together to develop best practices, training, staff development, advocacy, legislation, and more. There are resources out there designed to help with full integration. Be patient, work through issues, and make it a priority.”
No matter which model is used, integrating behavioral health services into a primary care setting offers an efficient way of ensuring that people have access to much needed behavioral health services. This can also help to minimize stigma and discrimination, while increasing opportunities to improve overall health outcomes. The most difficult challenges and barriers stem from differing clinical cultures, reimbursement systems and a fragmented delivery system. Successful integration requires the support of a strengthened primary care delivery system as well as a long-term commitment from clinicians and policymakers at the federal, state and local levels (Collins, Hewson, Munger & Wade, 2010).
Natalya Seibel is an administrative assistant for the Q Corp program team. She joined Q Corp in 2015 and supports work on various projects, including Total Cost of Care and continuing work with the Oregon Health Authority. For the past ten years, Natalya has worked in different roles in health care, cultivating a passion and focus on quality improvement. She has a Bachelor’s of Science in Psychology, and is pursuing a Masters’ in Health Care Administration at Portland State University. As a student, she is active in many local student/community groups centering on health care improvement and local government. She is an advocate for local mental health and the arts, and follows public policy intently. She moved to Oregon from New Mexico in 2007, and when not busy with work or school, she enjoys reading, local arts, karaoke and exploring nature around the Pacific Northwest.