The Commonwealth Fund recently featured Behavioral Health Integration: Approaches from the Field in their newsletter. This article profiles health systems, hospitals, and community health centers that have adopted integrated behavioral health and primary care integration despite lacking a direct source of reimbursement.
Those profiled include:
- Cherokee Health Systems, Knoxville, Tennessee – Federally qualified health center and community health center
- Carolinas HealthCare System, North Carolina – Integrated delivery system with more than 40 hospitals and 900 care locations
- Advocate Health Care, a Downers Grove, Illinois – Integrated delivery system with more than 250 sites of care including 12 hospitals
- Intermountain Healthcare, Utah and Idaho – Integrated delivery system with 22 hospitals and 185 ambulatory care clinics.
- St. Charles Health System in conjunction with PacificSource Community Solutions, Oregon – Care Coordination Organization comprises St. Charles Health System, a four-hospital system headquartered in Bend, Oregon, that joined with health plans, provider groups, dentists, community organizations, and others in the region to create the Central Oregon Health Council, the governance entity for PacificSource Community Solutions.
The profiles describe the organization and the unique approach used to integration, including impetus for change to integrated care, staffing, funding, and goals.
Review full profiles in the Commonwealth Fund newsletter article, Behavioral Health Integration: Approaches from the Field.
The Commonwealth Fund recently reported on new payment models as an impetus for integrating behavioral health and primary care. Coupled with the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act which builds on MHPAEA and requires coverage of mental health and substance use disorder services as one of 10 essential health benefits categories, significant barriers to integration are being removed. Patient convenience and their preference to avoid the stigma still attached to separate psychiatric care also play into the growing call for integration. Michael Hogan, PhD, points out that “All of this is creating a perfect storm to encourage integration.”
Behavioral health conditions are very common, affecting nearly 1 of 5 Americans and leading to health care costs of $57 billion a year. Conditions such as depression can be very disruptive, occurring in all ages, co-occurring with chronic medical conditions, and leading to significant disability. In spite of this, behavioral health care is mostly separated from the primary care system. The report further notes that the Institute of Medicine concluded 20 years ago that two largely independent systems of care for medical and behavioral health care produce poorer health outcomes and higher costs. While there has been mounting evidence of this, there have been significant barriers to integrating care, some of which remain, despite encouraging signs of progress. Integrated care is still rare, and there has been “little or no financial incentive or administrative advantage to bringing the two systems together.” Roger Kathol, MD, CPE, notes that “Payment is the heart of the problem.” The report profiles health care organizations that have made strides in integration and the fact that most of these have been accomplished, in part, through grants, Medicare and Medicaid demonstration programs, and the willingness of some health systems to absorb the initial costs of making this change.
Despite the progress, significant barriers to integrated care remain. Among those noted are:
“Health care 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.”—Benjamin Miller, PsyD, director of the Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine, and Academy Principal Investigator
“If we are going to look to develop a high-performing health care 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.”—Paul Summergrad, MD, American Psychiatric Association President
Please read the report in its entirety In Focus: Integrating Behavioral Health and Primary Care. Additional resources may be found in the Academy Literature Collection and by searching the Academy Portal for news and information on the topics of payment, policy, and parity.
A report, Eliminating Health Disparities through Culturally and Linguistically Centered Integrated Health Care Care:Consensus Statements, Recommendations, and Key Strategies from the Field was released in May 2014. It is the result of an expert consensus meeting convened by the U.S. Department of Health and Human Services Office of Minority Health convened to:
- formulate consensus statements,
- provide recommendations, and
- identify key strategies from practice for implementing integrated health and behavioral health care intended to improve health status for underserved populations.
The report is coauthored by Teresa Chapa, PhD, MPA, along with Katherine Sanchez, LCSW, PhD; Rick Ybarra, MA; and Octavio N. Martinez, Jr., MD, MPH, MBA.
While there is growing attention in research and the literature about integrated behavioral health and primary care, little attention has been paid to integrated care as a strategy for reducing health disparities. Using the AHRQ Academy definition from the Lexicon for Behavioral Health and Primary Care Integration, this consensus report notes that integrated care is “gaining significant momentum across the nation as a preferred approach to providing optimal care for behavioral health conditions, one that is more accessible and less stigmatizing than referral to specialty behavioral health care settings.”
The consensus panel examined the role of integration in eliminating health disparities, and, based on the most current and relevant literature,
“concluded that the improvement of behavioral health and physical health outcomes and the elimination of disparities for racial and ethnic minority and [limited English Proficiency] LEP populations can best be addressed by the integration of behavioral health and primary care services. The consensus statements and recommendations are intended to inform a broad audience of health and behavioral health care providers, educators, advocates, patients/ consumers and their families, researchers and policy makers. The goal of integrated care for racial and ethnic minority and LEP populations is to eliminate health disparities by focusing on the specific behavioral health care needs of populations who prefer treatment from their primary care physician and for whom disparities in behavioral health care prohibit access and result in poorer quality of care.”
The report also noted that implementation of these recommendations will
“require the comprehensive, persistent commitment of local, state and national leaders, especially as they relate to funding mechanisms, barriers that impede implementation, policies that help grow and sustain integrated health care programs, and data collection and research that enhance our knowledge base of how best to improve America’s health care system.”
The panel also called for this agenda to be widely distributed to medical and behavioral health care providers to reduce health disparities for underserved populations and to improve the health care delivery system overall.
An abstract of the report is at: http://www.ncbi.nlm.nih.gov/pubmed/?term=Eliminating+Health+Disparities+through+Culturally+and+Linguistically+Centered+Integrated+Health+Care%3A+Consensus+Statements%2C+Recommendations%2C+and+Key+Strategies+from+the+Field .
The full report is available for a fee at: http://muse.jhu.edu/login?auth=0&type=summary&url=/journals/journal_of_health_care_for_the_poor_and_underserved/v025/25.2.makariou-pikis.html
A study recently published in General Hospital Psychiatry found that veterans who received behavioral health screening in primary care are typically provided with adequate follow-up care. However, the care provided in all settings can be improved, along with supplementary efforts to align screening and treatment. The study examined primary care screening for depression, post-traumatic stress disorder (PTSD), and alcohol misuse at a U.S. Department of Veterans Affairs medical center.
Researchers evaluated 3 mental health screening tests given in 2011 to primary care patients who did not have prior behavioral health problems. They found 3,272 out of the 20,682 patients screened positive for one or more behavioral health disorders. Of the patients with positive screens, 12% screened positive for PTSD, 16% screened positive for depression, and 84% screened positive for alcohol misuse. The study found many patients received appropriate treatment in the primary care setting and those identified with more severe illness were more likely to receive care in a mental health setting. Furthermore, patients with positive screens for PTSD and depression who went on to be seen in mental health clinics received care that was consistent with treatment guidelines for that disorder. Patients identified with alcohol misuse did not receive recommended guideline medications in any care setting. A researcher noted the finding could be misleading since a positive screen on the screening tool identifies both alcohol misuse and alcohol dependence, but the two problems have different recommended treatments.
Pre-screening in primary care allows care providers to identify behavioral health conditions that would often go undiagnosed, as well as identify patients who may not seek services or wait to seek services until symptoms are more severe.
Rick Hafer, Ph.D, clinical professor of psychiatry and vice chairman of clinical services in the department of psychiatry at the University of Wisconsin School of Medicine and Public Health stated, “Early detection and treatment for mental health is similar to other medical conditions. Early intervention leads to more effective, efficient care. Since more than 60% of behavioral health conditions are treated in primary care, it is important to develop pre-screening tools to better evaluate mental health conditions and early intervention.”
Access the related Center for Advancing Health article: http://www.cfah.org/hbns/2014/mental-health-screening-in-primary-care-helps-veterans
Access the related study: http://www.ghpjournal.com/article/S0163-8343(14)00178-9/abstract
Despite the changing health care environment’s increasing need for primary care physicians that can manage populations, deliver care in interdisciplinary teams and address quality outcomes, national data indicate that not enough students and residents are choosing careers in primary care. According to family medicine organizations and researchers, “factors that influence specialty choice [include] individual learner characteristics, training and practice environments, and payment systems. The Annals of Family Medicine featured a paper titled The Four Pillars for Primary Care Physician Workforce Reform: A Blueprint for Future Activity that offers a framework with consistent language to guide efforts to increase the number of well-trained primary care physicians available to provide care. The foundation on which the four pillars stand is the Institute of Medicine’s definition of primary care which is:
“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”
The four pillars are as follows:
- Pipeline – the continuum of identifying, recruiting, and sustaining those students who are most likely to seek careers as primary care physicians
- Process of Medical Education – the traditional focus on curriculum development throughout medical student and residency education
- Practice Transformation – the transition to the Patient-Centered Medical Home
- Payment Reform – increases in primary care physician income with attention to funding for medical education
The first two pillars pertain mostly to all those under pressure to increase numbers of primary care graduates (e.g., medical school deans, admissions directors, curriculum committees). Insurance companies and larger health systems must address the third pillar. Finally, the fourth pillar, and most difficult one to achieve, must be addressed by state and federal legislators, insurers, health systems, professional organizations and the public.
The Council of Academic Family Medicine, which represents the family medicine academic organizations, has adopted the four pillars as their model to determine conditions that are conducive to increasing the number of primary care physicians. Other family medicine organizations including the American Academy of Family Physicians (AAFP), the American Board of Family Medicine, and the AAFP Foundation have also embraced this model as a strategy for growing the number of primary care physicians
Ultimately, this four-pillar framework is expected to provide family medicine organizations and other stakeholders with “consistent messaging for advocacy for appropriate primary care workforce development programs.” It can also serve as a frame work for medical associations and accreditation bodies, and it will be useful to the larger primary care community as it strives to provide quality health care for Americans.
Read more on the Four Pillars: http://www.annfammed.org/content/12/1/83.long
Take a look at the following funding opportunities:
Agency for Healthcare Research and Quality (AHRQ)
The Research Demonstration and Dissemination Grant (R18) is an award made by AHRQ to an institution/organization to support a discrete, specified health services research project. The project will be performed by the named investigator and study team. The R18 research plan proposed by the applicant institution/organization must be related to the mission and priority research interests of AHRQ.
The Research Project Grant (R01) is an award made by AHRQ to an institution/organization to support a discrete, specified health services research project. The project will be performed by the named investigator and study team. The R01 research plan proposed by the applicant institution/organization must be related to the mission and priority research interests of AHRQ.
AHRQ seeks to award cooperative agreements of up to three Centers of Excellence on Comparative Health Systems, as part of Patient-Centered Outcomes Research (PCOR) dissemination.
“As part of AHRQ's PCOR dissemination efforts, this AHRQ Funding Opportunity Announcement (FOA) invites applications for Centers of Excellence to identify, classify, track, and compare healthcare delivery systems ranging from integrated delivery systems to Accountable Care Organizations across the U.S. to help improve the speed of adoption and diffusion of CER-recommended practices through systems. See more at: http://grants.nih.gov/grants/guide/rfa-files/RFA-HS-14-011.html#sthash.BbR1p3YF.dpuf ”
Also, see AHRQ FOA Guidance: http://www.ahrq.gov/funding/policies/foaguidance/index.html
The Institute for Patient and Family Centered Care (IPFCC) provides leadership and resources for advancing the practice of patient- and family-centered care. IPFCC promotes collaborative, empowering partnerships among patients, families, and health care professionals and organizations.
IPFCC serves as an information resource center for patient and family leaders, clinicians, administrators, educators, researchers, and facility designers who are interested in advancing the practice of patient- and family-centered care. In addition, IPFCC provides consultation, training, and technical assistance to hospitals, clinical practices, educational institutions, architecture firms, community organizations, and agencies at state, provincial, and federal levels.
A broad variety of resources and publications, including assessment tools and guidance publications, has been developed by the Institute.
One area of focus for IPFCC is Primary Care/Medical Home. IPFCC introduces this topic as follows:
“The core principles of patient- and family-centered care serve to make primary care responsive to the concerns and priorities of all. Patients and their families are involved as partners in their own care as well as in planning, implementing, and evaluating improvements to the systems of care…Further, it acknowledges that families—however that term is defined by the patient—are essential to patients' health and well-being and are allies for quality and safety.
Primary care providers who practice patient- and family-centered care know that high-quality, safe care requires partnerships with patients and family members as well as with other care providers and community members. This approach enhances the quality and experience of care for patients and families and the quality of the work experience for practitioners and staff.”
For information on how to provide patient- and family-centered care in your practice, consider:
To see the key concepts of patient- and family-centered care in ambulatory care settings, review: Patient- And Family-Centered Ambulatory Care: A Checklist .
Research from the April 2014 issue of American Mental Health Counselors Association’s (AMHCA) Journal of Mental Health Counseling (JMHC) indicates that, “integrating behavioral health and primary care poses the best shot at slowing down the rate of escalation in health care costs — bending the cost curve — that has been to driven upward by ineffective but expensive care for individuals with chronic comorbid health conditions.” The JMHC April issue on “Mental Health in Primary Care,” corresponds to AMHCA’s new initiative to connect clinical mental health counselors (CHMCs), other practitioners, and researchers to assist [AMHCA members] on integrated care opportunities through the AMHCA Strategic Counselor Engagement and Network Technology (ASCENT) Program.
Journal contributors of the April issue will partner with other practitioners to help counselors find innovate ways to translate the recommendations in the special issue into everyday practice, and to engage primary care physicians and specialists. The goal of the ASCENT effort “is to create more mental health-primary care collaborations among CMHCs, in order to foster optimal, patient-centered, holistic care — in particular for newly insured, underserved, low-resourced racial minority and rural populations.”
The ASCENT initiative is part of AMHCA’s Forum for Learning Opportunities and Working Technical Assistance Collaborative, an electronic forum for sharing and learning about care-delivery measures that address the needs of AMHCA members. ASCENT streaming activities are related to themes highlighted in the JMHC through a set of virtual sessions in which the April journal contributors will discuss their findings and recommendations with counselors and other practitioners. Topics introduced in the set of “conversation starter” virtual sessions include:
- Basic competencies on integrated care and training in primary care settings,
- Providing culturally and linguistically competent care, and
- How to work with primary care physicians to address the needs of patients with comorbid or complex conditions.
The 2014 sessions are scheduled for July 31, August 19, and September 11. After the sessions conclude, Cross-Segment Working Groups of AMHCA members will meet regularly to track and hypothesize from others’ efforts, providing a valuable source of effective integrated care and leading to ideas to develop additional approaches to integrated care.
Access the related article: http://onlinelibrary.wiley.com/doi/10.1002/mhw.20434/pdf
Access more information on the ASCENT program: http://www.amhca.org/member/ascent.aspx
The Office of the National Coordinator for Health Information Technology (ONC) recently published a 10-year vision paper inviting health IT stakeholders to join ONC in developing a defined, shared roadmap to achieve health IT interoperability. The report states, “The U.S. Department of Health and Human Services (HHS) has a critical responsibility to advance the connectivity of electronic health information and interoperability of health information technology (health IT).” Furthermore, the ability to seamlessly share information from one setting to another is of great importance to patients, nurses and thus to nurse informaticists, experts in the “specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, knowledge, and wisdom in nursing practice.” Two facets have been identified to achieve optimal information sharing.
First, complete, valid, and up-to-date patient information is required for care providers to administer optimal care to patients, decrease costly errors, and promote care coordination across different health care settings.
Second, the design of systems must support the capture and transmission of all documented data. Then, the aggregate data can be used to inform future patient care, demonstrate the impact of nursing care on patient outcomes and provide data-based support for population health management.
Currently, our nation is experiencing an increase in the number and proportion of older adults in the U.S. population; many of whom are diagnosed with multiple chronic conditions and require complex and coordinated care. “Without maximally available and complete patient data, we will lose the opportunity to provide the best possible, most effective and efficient coordinated care for these patients as they transition from one setting to another or one provider to another.” Hence, nurse informaticists are needed to provide leadership and promote solutions for information management and care coordination.
Access the HIMSS article: http://www.himss.org/News/NewsDetail.aspx?ItemNumber=30781&navItemNumber=17425
In 2010, the Veterans Health Administration (VHA) began the Patient Aligned Care Teams (PACT), a nationwide initiative “that reorganized care at all [their] primary care clinics in accordance with the patient-centered medical home [PCMH] model.” The goal of PACT is to provide comprehensive, longitudinal, patient-centered primary care by establishing team-based care, increasing access to same-day care, improving care management and coordination, and increasing focus on patient-centeredness. It also builds on efforts to integrate behavioral health and primary care that were started in 2007. A recent study of 11 million primary care patients analyzed PACT data from fiscal years 2003-2012 to monitor changes in health care utilization and cost after implementation. Results show that after 2-1/2 years, PACT caused a slight decrease in hospitalizations for ambulatory care-sensitive conditions and specialty mental health visits, and a slight increase in outpatient primary care visits for patients 65 years and older. These effects avoided $596 billion in costs where $774 billion was initially invested in the initiative. Although there was no positive return on investment and a net loss of $178 million, PACT is still evolving and these trends in utilization and cost avoidance are favorable. Thus, the PCMH model does not pose a huge financial risk for the VHA.
The costs PACT avoided were largely due to the decline in specialty mental health care visits. This reduction may have been enabled by the integration of primary care and mental health. Because mental health care was more accessible in primary care, PACT teams perhaps had less need to refer patients to specialty mental health services. In turn, the increase in primary care visits might have also contributed to these cost savings. Due to counseling of patients with complex chronic conditions by PACT nurse care managers, patients might have been encouraged to shift more of their care from Medicare to the VHA. Although, this trend may have increased visits within the VHA, it nullified costs associated with obtaining care elsewhere. Over time, these factors’ impacts on cost savings will become clearer. Still, savings are expected to remain if other components of PACT become well integrated into primary care. Nonetheless, the VHA’s adoption of the PCMH model has certainly improved the quality of and satisfaction with care.