Recent Collaborative Family Healthcare Association (CFHA) blog posts have featured approaches to supervision of behavioral health professionals in primary care. Part I, featured in March by the Academy, was written by staff at Cherokee Health Systems .
Part II, featured here, was written by staff at Access Community Health Centers, a federally qualified health center that provides integrated primary care services at three locations in Madison, Wisconsin. They have been identified by the Agency for Healthcare Research and Quality as a Service Delivery Innovation. They began providing integrated care once they realized that many patients who are referred to behavioral health services in the community do not follow up on these referrals. To deliver their care, Access Community Health Centers employs five full-time psychologists, three full-time social workers, and a part-time consulting psychiatrist. All of these employees work together with the primary care provider to provide care and monitor health, though the primary care provider (PCP) maintains decisionmaking authority.
Due to the pace and intensity of behavioral health in primary care, trainees need specialized supervision to foster and monitor progress. Over the past 9 years, Access Community Health Centers has taken trainees from various backgrounds: clinical psychology, counseling psychology, rehabilitation psychology, Marriage & Family Therapy programs, social work programs, and some fellowship positions for PhDs and PsyDs. Live shadowing allows for the supervisor to be present for the visit with a patient, and this can make visits more efficient, as the trainee and supervisor work together to provide the best care for the patient.
The typical training scenario includes many steps. Trainees first shadow a behavioral health provider, and then a PCP. Next, they begin to see patients on their own but still work with supervisors beforehand to plan and organize visits. There is also discussion about staying flexible for the patient’s needs and to help address issues the PCP expects. Supervisors either shadow these visits or speak with trainees afterwards to review notes. Trainees meet with their supervisors before presenting their findings and thoughts to the PCP. Trainees are coached to focus on one or two issues with the patient at each visit, which requires the trainee to be able to assess and triage needs and prioritize options.
Trainees also learn how to work in a primary care environment. They are trained in how to efficiently communicate with PCPs, and they work alongside with them so as to gain an appreciation for their needs. Primary care setting supervision works best when it mirrors the pace and culture of the clinic itself.
Read the related article:
Read more about Access Community Health Centers:
Read about Part I of the CFHA blog posts on the portal:
A team of researchers led by Rodger Kessler has developed the Vermont Integration Profile (VIP), “a set of standardized measures of integrated care processes to use in both practice implementation and improvement efforts and in research.” As explained in the Research in Progress feature of the Health Psychologist Newsletter of the American Psychological Association Division 38, the VIP was developed based on the Lexicon created by National Integration Academy Council (NIAC) member C.J. Peek, PhD. The Lexicon is a set of concepts and definitions for what is meant by behavioral health and primary care integration, and was developed by expert consensus.
The VIP comprises 30 items in six dimensions: (1) practice workflow, (2) clinical services and providers, (3) workspace arrangement, (4) shared care and integration method, (5) case identification, and (6) patient engagement and retention. The VIP can also be used to calculate a total score for degree of integration. In a study with 139 respondents from 113 practices, the researchers were able to use the VIP to detect different levels of integration, which correlated with different types of practices. Exemplar sites, which were considered to be the most advanced in behavioral health integration, had an average total score of 62.04 out of 100, while Community Health Center and Medical Practices without Behavioral Health Care averaged only 35.76 out of 100. The fifth most current version of the VIP takes less than 10 minutes to complete and is automatically self-scored. Although the VIP is still being revised, the researchers are confident that they have created a “usable, theoretically drive set of measures relevant to the field and a product that can assist in the evaluation of behavioral health integration models.”
In commentary about the development of joint principles of Patient Centered Medical Homes (PCMHs), The Working Party Group on Integrated Behavioral Healthcare reiterated the importance of the integration of behavioral health into the delivery of primary and specialty medical care, and note it as a core principle of the PCMH. Tools such as the VIP will allow researchers and practitioners to determine the effectiveness of various integrated care models.
The VIP research team states:
“There is a need to measure differences in approaches to behavioral health services in primary care settings. We have translated Peek’s theoretical construct of behavioral health integration into a brief self-report measure with encouraging early evidence of reliability and validity. Our hope is to further develop this instrument to evaluate and measure the processes associated with the growing presence of behavioral health in primary care…Although the VIP is undergoing continued testing and refinement, we believe we have established a usable, theoretically driven set of measures relevant to the field and a product that can assist in the evaluation of behavioral health integration models.”
The VIP can also be used to inform quality improvement efforts and evaluate the degree of practice integration in relation to differences in outcomes.
NOTE: The newsletter states that readers can contact Rodger Kessler, Ph.D., ABPP (Rodger.Kessler@med.uvm.edu) for questions regarding the VIP and copies of the instrument to review and complete.
The American Psychiatric Association (APA) released in March 2015 new training recommendations calling for residency programs to educate the next generation of psychiatrists in integrated behavioral health care. These training recommendations inform all spans of a practicing or prospective psychiatrist’s education, including undergraduate and graduate medical education as well as continuing medical education.
Given the current transformation going on in our health care system and the new models of health care delivery that are emerging, it is likely that the role of psychiatrists will change. APA believes that psychiatric education must prepare current and future psychiatrists to deliver patient-centered, team-based care. These recommendations intend to break down barriers between mental health and physical health and to support psychiatrists’ work in tandem with primary care doctors to address a patient’s total health care. The integrated care model helps address shortages to all types of mental health providers that exist in parts of the United States. Among these are models that increase access to psychiatrists having a psychiatrist in the primary care office or available through use of telepsychiatry.
In a recent news release, Richard Summers, M.D., chairman of the APA’s Council of Medical Education and Lifelong Learning, which developed the report, stated:
“We identified emerging integrated care models that are important for overall system change and therefore important to the world of education, because practitioners were going to need to develop a new set of skills, new ways of collaborating, new knowledge and new cultural values to be able to practice in these new models.”
Key recommendations include:
- Emphasis of inter-specialty education in all training programs, in order to help physicians develop the attitudes and skills necessary for collaborative practice;
- Early exposure (in undergraduate medical schools) to primary care settings that utilize effective integrated behavioral health; and
- The development of faculty members (in graduate medical education programs) with interest and experience in integrated behavioral care to teach and supervise residents and to advocate for collaborative practice in the institution.
Ultimately, APA believes that moving to integrated behavioral health care will reduce health care costs and improve access to mental health services.
Additional APA resources on integrated behavioral health care can be found at:
- Integrated Primary & Mental Health Care: Reconnecting Brain & Body
- Role of Psychiatry in Health Care Reform Board of Trustees’ Work Group on Health Care Reform
- Economic Impact of Integrated Medical-Behavioral Healthcare: Implications for Psychiatry
Additional resources on integrated behavioral health and training of psychiatrists are at:
- Teaching Psychiatry Residents to Work at the Interface of Mental Health and Primary Care
- Training in Integrated Mental Health-Primary Care Models: A National Survey of Child Psychiatry Program Directors
- The practice of psychiatry in the 21st century: Challenges for psychiatric education
- Addressing mental health care disparities through interdisciplinary training in integrated health care, cultural competence, and family systems
Posted April 2015
Behavioral health disorders are a major public health problem in the United States. An estimated 26.4 percent of the U.S. population suffers from diagnosable mental disorders that are directly related to poor health outcomes, increased costs, and premature deaths. An estimated $113 billion was spent in mental health treatment in 2005, of which about $22 billion was spent in substance use treatment alone. It is expected that behavioral health disorders will surpass all physical diseases as the leading cause of disability worldwide by 2020.
The National Quality Forum (NQF) designed and implemented a multiphase program to improve the delivery of quality behavioral health services and improve behavioral health status of Americans. NQF has now endorsed behavioral health measures for depression, child and adolescent mental health, health screening and assessment, and substance abuse, and has made them available for public review. A complete list of endorsed measures can be viewed here.
Here is the appeal process: “Any party may request reconsideration of the 17 endorsed quality measures by submitting an appeal no later than April 7 at 6:00PM ET. To submit an appeal, go to the NQF Measure Database. For an appeal to be considered, the notification must include information clearly demonstrating that the appellant has interests directly and materially affected by the NQF-endorsed recommendations and that the NQF decision has had (or will have) an adverse effect on those interests. All appeals are published on the NQF website.”
For more information, please contact Elisa Munthali at 202-783-1300 or via email at firstname.lastname@example.org.
Access Community Health Centers is a federally qualified health center that provides integrated behavioral health and primary care services. With three integrated care clinics in Madison, Wisconsin, the Agency for Healthcare Research and Quality (AHRQ) has identified Access Community Health Centers as a Service Delivery Innovation.
Access Community Health Centers began providing integrated care because of the realization that many patients referred to behavioral services in the community did not follow up on the referrals. The care clinics provide care to vulnerable populations, including patients who are impoverished, medically or socially complex, and mentally ill. A majority of patients receive Medicaid benefits, one-third of patients are minorities, and one-fifth of patients speak a language other than English.
To deliver integrated care, Access Community Health Centers has a behavioral health team consisting of five full-time psychologists, three full-time social workers, and a part-timer consulting psychiatrist. The psychiatrist spends 10 hours per week in the primary care clinics. Practicum students, medical residents in psychiatry, and postdoctoral fellows also work there. This staff is distributed among the three care centers. An initial assessment of behavioral health needs among the patient population led physicians to believe “they could handle many of the cases currently being referred if they had more support from psychologists or social workers.” In the beginning, only a part-time consulting psychologist was used. However, patients had more complex needs than expected which led the care team to introduce psychiatric services. The consulting psychiatrist sees patients for a one-time consultation rather than for repeat visits, which allows the psychiatrist to see more patients. All members of the care team have complete access to patient medical records. The behavioral health team, consulting psychiatrist, and primary care providers work together to provide care and monitor patient health. However, the primary care provider maintains decision-making authority.
Integrated care has resulted in increased access to behavioral health services, more engaged patients, more screening for depression, more documentation of behavioral goals, fewer referrals, and less medication use. AHRQ lists the evidence rating as moderate based on “pre- and post-implementation comparisons of various measures of primary care clinician involvement in behavioral health treatment” and “post-implementation trends in the number of primary care patients accessing behavioral health services in the primary care clinics.”
There is growing consensus that there is an increasing need for enhanced teamwork if primary care practices are to be efficient and effective. This study, Electronic health records and support for primary care teamwork, examines how electronic health records (EHRs) facilitate teamwork, as well as what challenges they pose, and what practices do to overcome those.
This qualitative study was done in a selected subset of practices that were recognized as patient centered medical homes using the National Committee for Quality Assurance 2011 assessment tool. The study found that EHRs facilitate communication and task delegation through
- instant messaging,
- task management software, and
- the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses.
Respondents felt that areas in which EHR functionalities were weakest and posed challenges to teamwork included
- the lack of integrated care manager software and care plans in EHRs,
- poor practice registry functionality and interoperability, and
- inadequate ease of tracking patient data in the EHR over time.
While practices developed solutions for some of the challenges they encountered, they expressed a need for “more permanent vendor and policy solutions for other challenges.”
The authors state the following conclusions:
“EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time.”
The full study is available at: http://jamia.oxfordjournals.org/content/jaminfo/early/2015/01/26/jamia.ocu029.full.pdf
Posted March 2015
The National Action Alliance for Suicide Prevention’s Research Prioritization Task Force (RPTF) published a Prioritized Research Agenda for Suicide Prevention: An Action Plan to Save Lives in February 2014. The Plan seeks to reduce rates of suicide attempts and deaths in the next 5-10 years. The Research Agenda focuses on six different questions, which will be addressed in a series of webinars sponsored by the National Council for Behavioral Health with the Action Alliance, and the National Institute of Mental Health. The topics and dates for the 2015 webinar series are listed below:
January 29 — Why do people become suicidal? View past recording.
February 24 — How can we better detect/predict suicide risk? View past recording.
April 2 — What interventions prevent suicidal behavior? Register.
April 29 — What are the most effective services to treat and prevent suicidal behavior?
May 27 — What suicide interventions outside of health care settings reduce risk?
June 24 — What research infrastructure do we need to reduce suicidal behavior?
Additional information about the webinar series will be posted on the Academy event calendar as it becomes available.
For more information, see:
Posted March 2015
New Research Opportunity
Take a look at the following funding opportunity:
Department of Health and Human Services Health Resources and Services Administration (HRSA)
Rural Health Care Coordination Network Partnership Program
HRSA announced a grant opportunity, Rural Health Care Coordination Network Partnership, “to support the development of formal, mature rural health networks that focus on care coordination activities for the following chronic diseases: diabetes, congestive heart failure (CHF) and chronic obstructive pulmonary diseases (COPD).” The aim of this program is to provide accessible and coordinated quality health care for people with chronic conditions in rural areas. The Request for Application (RFA) cites the importance of caring for the whole person and the importance of integrating behavioral health in primary care.
“There are often psychosocial (psychological and social) issues related to chronic diseases…In addition, more mental health problems are seen in the primary care setting than other health care settings; thus, integrating behavioral health care into primary care helps address both the physical and psychosocial aspects of health and wellness. Reviews and reports from the Agency for Healthcare Quality and Research (AHRQ) have shown a positive impact from integrating a team approach to care for a variety of disease conditions.  Health care coordination for people living with chronic conditions is vital to providing high quality care, especially in rural areas where access to health care is an issue.”
 Jortberg BT, Miller BF, Gabbay RA, et al. Patient-centered medical home: how it affects pyschosocial outcomes for diabetes. Curr Diab Rep. 2012;12:721-728. PMID: 22961115.
For more information about the funding opportunity see: http://www.grants.gov/view-opportunity.html?oppId=273226
Posted March 2015
Promising findings from two large-scale tests of advanced primary care: the Comprehensive Primary Care (CPC) initiative and the Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration were just announced by Dr. Patrick Conway, the Centers for Medicare & Medicaid Services (CMS) Deputy Administrator for Innovation and Quality and Chief Medical Officer.
Some of the grantees in both the CPC initiative and the MAPCP demonstration are primary care practices that are integrating behavioral health.
The reported first-year results illustrate the potential for steady improvements in the participating practices’ advanced primary care capabilities. The CMS anticipates continued improvements as the participating practices deepen and refine their methods of delivering advanced primary care so that patients can continue to receive improved quality and coordination of care.
The full report is available at: http://innovation.cms.gov/Files/reports/CPCI-EvalRpt1.pdf
Descriptions of the practices involved in these efforts can be found at http://innovation.cms.gov/initiatives/comprehensive-primary-care-initiative/ and http://innovation.cms.gov/initiatives/Multi-payer-Advanced-Primary-Care-Practice/index.html
There has been little research in the literature in the last few years on treating substance use disorders (SUD) in an integrated behavioral health and primary care setting. A good deal more research is available on treating mental health disorders in the integrated care setting. Most of the more current publications have been summarized on the Academy Portal, and may be found by using the general search function.
With regard to policy and financing related literature, we would refer you to the following publications:
The cost effectiveness and sustainability of treating SUDs in the Integrated medical and behavioral health setting is addressed in: Manderscheid R, Kathol R. Fostering sustainable, integrated medical and behavioral health services in medical settings. Ann Intern Med. 2014 Jan;160:61-65. PMID:24573665, which is found at: http://annals.org/article.aspx?articleid=1811029
There are significant barriers to integrating SUD with primary care. A recent study indicates many of these “arise at the policy level and are addressable.” For more information, see: Urada D, Teruya C, Gelberg L, et al. Integration of substance use disorder services with primary care: health center surveys and qualitative interviews. Subst Abuse Treat Prev Policy. 2014 March; 9:15. PMID: 24679108., which may be found at: http://www.substanceabusepolicy.com/content/pdf/1747-597X-9-15.pdf