Two recently published studies highlight the benefits of integrating behavioral health in primary care for children and youth.
- Integrating behavioral health (BH) into pediatric care might lead to short- and long-term improved health outcomes for children, argues a recent Viewpoint article published in the Journal of the American Medical Association. Childhood disorders such as asthma, obesity, and diabetes are being recognized as having a large behavioral component. Research has also shown that childhood behavioral disorders can contribute to poor physical health into adulthood. Severe early life stress such as exposure to violence or abuse has been linked to both behavioral disorders in children and a variety of poor health outcomes including premature death in adults. Several evidence-based interventions have demonstrated that behavioral intervention for children and their families early in childhood can lead to improvements in outcomes. Implementing behavioral medicine interventions within medical care settings, allows for the potential of reaching children early on and in an environment in which the family may be more open to receiving treatment.
“Organized medicine has an opportunity to ensure healthy starts for children, cognitively, behaviorally, and physically by using health care in primary care settings as the intervention venue.”
Integrating BH into primary care (PC) practice is becoming more prevalent. Small studies have demonstrated that promoting parenting, as well as screening parents and children for behavioral health concerns (e.g., depression) in the PC setting is feasible. There are several barriers to integrating in early child health care, including reimbursement issues for providing this type of care and lack of training in BH for current health professionals. Despite these barriers, efforts to integrate BH into child health care should be promoted and funded. Primary child health care provides an excellent opportunity to behaviorally intervene and improve children’s lifelong health and well-being.
- Findings from a study recently published in The New England Journal of Medicine indicate a need for increased BH services for children and adolescents within primary care settings. The study found that rates of severe mental illness in youths have dropped substantially in the last decade and outpatient mental health treatment and psychotropic-medication use increased during the same time period, particularly among those with severe mental illness. These findings come from nationally representative survey data from the Medical Expenditure Panel Surveys from 1996-1998, 2003-2005, and 2010-2012, with more than 50,000 persons included in the analysis. While rates of treatment increased, the results also showed that only a quarter of young people with severe mental health issues received psychotherapy and 31percent reported psychotropic medication use, indicating that there may be a need for improved access to BH providers. The majority of young people in this study with severe mental illness received no mental health care. The authors concluded that schools and primary care settings could improve methods for identifying youths most in need of treatment and referring them to get the appropriate care.
The two studies are at:
In the first installment of the integrated care column in Psychiatric Services, Margaret A. Swarbrick, PhD, discusses the importance of wellness-oriented peer approaches. In peer-based approaches, individuals who have mental illness diagnoses and are current or former users of the mental health system offer aid and support to patients. Peer providers use their lived experiences with mental illness, plus skills learned in formal training, to deliver whole-health services to patients with mental health and substance use disorders.
The peer wellness movement began 40 years ago with the intention of providing support to patients with mental illness outside the traditional mental health system through advocacy and policy reform. Since then, the peer movement has also become a complement to the mental and medical health delivery systems. Because of the movement’s focus on whole-health, peers are an “important complement” to the integration of primary care and behavioral health. Peer providers can work alongside integrated primary care teams to provide support to patients who could benefit from lasting behavioral health changes and self-management techniques.
Peers serve in roles such as peer wellness coaches (PWCs) and peer whole health specialists (PWHSs). PWCs and PWHSs work with patients to address modifiable risk factors, such as diet, physical activity, and smoking. Peers emphasize self-management techniques that empower patients to be responsible and proactive in maintaining their health. In addition to what peers have to offer patients, peers can also teach medical professionals to “offer education, guidance, support, and informed shared decision making.”
Another benefit to using a peer approach is that they tend to be less expensive than nurses and social workers. Some states even provide Medicaid reimbursement for services provided by peer specialists. There are, however, challenges to utilizing a peer wellness approach in integrated care. For example, collaboration between the patient, PWC, and medical care team may conflict with how medical care providers have been trained to practice. To overcome this barrier, “the team should be trained in creating a safe, non-judgmental environment in which the peer provider is an active participant on the team.”
Read the column here: http://ps.psychiatryonline.org/doi/pdf/10.1176/appi.ps.201300144
Additional information available from: http://www.integration.samhsa.gov/workforce/peer-providers
Oregon’s Alternative Payment Methodology (APM) model may be a promising approach to financing and sustaining behavioral health (BH) integration efforts, suggests Deborah Cohen, PhD, in an April, 2015 blog post in Health Affairs Blog entitled “Addressing Behavioral Health Integration with Payment Reform.” Dr. Cohen, an Associate Professor in the Department of Family Medicine at Oregon Health & Science University, is part of the team evaluating the Oregon APM model. Based on her experiences with over 25 integrated care clinics throughout the country, she explains that “integrated care is comprehensive primary care.” Integrated care is designed to address both medical and behavioral patient concerns within one setting, allowing for whole-person primary care (PC).
Despite growing interest in integrating BH and PC, several financial barriers make integration difficult to achieve. The author highlights three barriers:
- Inability of many practices to afford a BH clinician.
- Lack of funds to pay for necessary clinic renovations to provide space of BH providers to see patients within the PC clinic, rather than having an off-site office.
- The traditional 50-minute therapy session and payment structure for BH providers, which means that BH providers are inaccessible for warm hand-offs and that hiring enough providers to see patients would be cost prohibitive.
If health providers (PC and BH providers) are paid in a fee-for-service model, surmounting these barriers is very difficult.
The APM pilot is testing the notion that a per-member-per-month (PMPM) fee structure can support the provision of comprehensive care. For some clinics, the APM pilot has allowed for “experimentation” with integrating BH into the PC team. Dr. Cohen explains that:
“While APM is not specifically funding primary care-behavioral health integration, it is freeing up practices to look more broadly at how they treat their patients. The practices in the APM pilot do not have requirements for how to they spend their PMPM fee. Therefore, instead of needing to generate a high number of physician-patient primary care visits, they now have the flexibility to spend some of their fees on behavioral and mental health services. As long as the net effect is budget-neutral, they can treat patients in new ways and with new combinations of providers.”
The APM model may bring the health care system one step closer to a payment structure that allows PC clinics to integrate BH services in a way that is financially sustainable. In addition to initiating a payment structure that makes integrated care financially feasible, the author notes that for comprehensive, integrated PC to become “common place will require leadership to push further on paying for services that are central to comprehensive primary care, align payment across payers to reduce complexity, and support system-wide practice change.”
Blog post may be found at: http://healthaffairs.org/blog/2015/04/20/addressing-behavioral-health-integration-with-payment-reform/
Two recent Health Affairs blog posts cite strategies to re-engineer Graduate Medical Education (GME) to better serve integrated primary care.
- Expansion of the Teaching Health Center Graduate Medical Education (THCGME) program could help to address the current primary care physician shortage as well as the mental health workforce shortage, according to the authors of two Health Affairs Blog posts. The first post “Teaching Health Centers: Targeted Expansion for Immediate GME Reform” proposes modifications to the recently developed THCGME program to meet the growing primary care needs of the United States population. The lead author of the blog post is Dr. Richard Rieselbach, Professor Emeritus at the University of Wisconsin School of Medicine and Public Health. Eight additional co-authors contributed to the post as well. They explain, there are currently “sixty THCGME programs in 24 states […] training over 550 residents.” Evidence indicates that “over 90 percent of graduates” from the THCGME programs intend to work in primary care, with a higher than average rate indicating intention to work in underserved communities. The authors call for legislation to establish sustainable support for the THCGME program as well as support for program modification and enhancement, given the critical need for primary care providers. The proposed THCGME enhancements include increasing the number of funded residency positions, emphasizing training in rural and urban underserved areas, and modifying graduate medical education (GME) curriculum to integrate training in behavioral medicine. Implementing the proposed modifications could increase the number of well-trained providers entering the primary care workforce, alleviating a portion of the primary care provider shortage. However, these changes cannot be achieved without enacting legislation to provide sustainable and increased support for the THCGME program.
“This relatively simple, widely supported initiative can accelerate GME training to deliver a new generation of physicians prepared to provide the right care and services to patients when and where they are needed.”
- The second post, “Integrating Behavioral Medicine into Primary Care GME: A Necessary Paradigm for 21st Century Ambulatory Practice,” describes the advantages of incorporating behavioral medicine training into the THCGME program for pediatricians, general internists, and family medicine physicians in light of the current mental health workforce shortage. The lead author is Dr. Alan Axelson, the Medical Director of InterCare Psychiatric Services in Pittsburg. The seven authors argue that THCGME curriculum should include training in medication management as well as brief evidence-based psychotherapy or counselling for treating common mental health (MH) issues encountered in primary care (PC) settings. Treating MH issues in PC may be beneficial for many reasons such as reducing stigma for patients and patients may be more likely to seek help from a provider with whom they have an established relationship. Additionally, if PC providers are trained to provide treatment for common MH disorders, this may allow “mental health clinicians to focus on the most challenging patients.” The THCGME curriculum may also be expanded based on the specific PC discipline to include training in geriatrics, preventive medicine, palliative medicine, and public health. Integrating behavioral medicine as well as other areas of training into the existing THCGME curriculum may help prepare “effective and knowledgeable leaders” for the primary care workforce.
Blog posts may be found at:
GME recommendations by the Institute of Medicine may be found at:
Until 2010, Federal agencies defined health disparities very generally as “differences in health among different population groups.” The term was originally coined not merely to describe “all possible health differences among all possible groups of people” but rather to refer specifically to the poorer health outcomes experienced by socially disadvantaged people. Thus, in 2010, Healthy People 2020 clarified the meaning of health disparity by defining it as
“. . . a particular type of health difference that is closely linked with economic, social, or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, or mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”
Health equity is defined as
“the principle underlying a commitment to reduce—and, ultimately, eliminate—disparities in health and in its determinants, including social determinants. Pursuing health equity means striving for the highest possible standard of health for all people and giving special attention to the needs of those at greatest risk of poor health, based on social conditions.”
These explicit definitions of health disparities and health equity ensure that allotted resources are used for intended purposes.
In addition, the definitions of health disparities and health equity emphasize health differences specifically with regard to economic/ social disadvantage for many reasons:
- First, a large body of evidence associates “economic/social disadvantage with avoidable illness, disability, suffering, and premature death.”
- Second, economic/social disadvantage can be mitigated by social policies such as new minimum wage laws and anti-discriminatory housing and employment practices.
- Moreover, “health is needed for functioning in every sphere of life” and should therefore be fairly distributed.
- International human rights principles call for everyone to have a fair chance at health, well-being, long life, and social and economic opportunity and declare health disparities as discriminatory and inequitable.
Health disparities and health equity are interrelated. Health disparities are the way in which we measure progress towards health equity or social justice in health. A reduction in health disparities means greater health equity, and achieving greater health equity requires that we selectively improve the health of the economically/socially disadvantaged without worsening of the health of others.
Read the related article: http://www.publichealthreports.org/issueopen.cfm?articleID=3074
A study, published in Pediatrics in March of 2014, revealed a significant level of unmet need for care coordination among parents of children with a mental health condition. Care coordination is a way of connecting children with special health care needs and their families to critical services and resources. This type of care has been linked to lower health care costs, better health outcomes, and it helps families to use the health care system more efficiently. Coordinated care is especially important for children with mental health conditions because their families often have greater difficulty accessing specialty care for their child’s health problems.
The study’s authors analyzed data from the 2007 National Survey of Children’s Health to get a better understanding of the frequency of need for coordinated care and to identify factors that related to this need being unmet. The research sample included more than 7,500 children from ages 2 to 17 years with a diagnosis of depression, anxiety, attention-deficit/hyperactivity disorder, or conduct disorder who had received two or more types of preventive or subspecialty health care services in the last year. The need for care coordination was assessed with a single question: “During the past 12 months, have you felt you could have used extra help arranging or coordinating the child’s care among different health care providers or services?” A large proportion of parents (43%) reported a need for care coordination. Among the parents expressing a need for this type of care, 41% indicated that this need was not met. The authors then looked at sociodemographic, clinical, and parent psychosocial characteristics, to understand which factors may be linked to having an unmet need. They found that parents of children with an anxiety disorder, parenting stress, low income, and public or no insurance were more likely to have unmet need. Whereas, those who reported social support and family-centered medical care seemed be less likely to have unmet coordinated care needs.
This study highlights the need for care coordination among children with mental health conditions and their families, particularly those with anxiety. The study authors concluded from these results that “delivery of family-centered care and enhancing family supports may help to reduce unmet need for care coordination in this vulnerable population.” In a Culture of Health blog post from the Robert Wood Johnson Foundation (RWJF), the first author, Nicole M. Brown, MD, from the RWJF Clinical Scholars Program, commentated that the findings also point to a “need for more training for physicians to help us recognize and diagnose anxiety and other mental health conditions earlier” in order to help connect children and their families to appropriate mental health services.
Link to the article:
Link to blog post with Nicole Brown, MD discussing the study:
Parents respond positively when primary care providers (PCPs) address behavioral health (BH) concerns, a recent study shows. The article, “Do Parents Expect Pediatricians to Pay Attention to Behavioral Health?” is published in Clinical Pediatrics. Pediatricians may be uniquely positioned to deliver BH interventions because they see more children than BH providers, they have an existing relationship with the child and the family that may make the child more receptive to receiving BH care, and receiving mental health treatment within a medical clinic may help to reduce the stigma often associated with mental health care. The American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics has recommended that PCPs take on more of a role in delivering BH care in pediatric primary care. Already, PCPs prescribe the majority of medications for children for attention-deficit/hyperactivity disorder and depression. With the focus of pediatric primary care visits expanding beyond simply physical health, it is important to assess how parents are responding to PCPs addressing their child’s mental health. In this study, parents (or guardians) of children were interviewed to understand the expectations that parents and guardians have in term of the role PCPs play in their child’s BH, as well as to understand parents’ reactions to PCPs behavioral interventions.
This study included 55 parents/guardians, with a child between the ages of 2-17 years, who was seen at an urban primary care clinic and referred to a mental health center. The results from the interviews found that parents/guardians differed in their view of the role of the PCP. Forty-seven percent perceived the PCP role as providing only physical health care; whereas, 53 percent expected the PCP to play a role in both physical health and BH. When parents/guardians were asked about their reaction to the PCP’s intervention for their child’s behavioral or mental health, 97 percent expressed a positive reaction. In particular, parents/guardians tended to have a positive reaction when the PCPs actions matched the parent’s/guardian’s expectations for the visit.
This study demonstrated that overwhelmingly parents respond well to PCPs addressing the BH needs of their children during pediatric visits, with some parents expressing “greater appreciation for the PCP after he or she addressed a behavioral health issue.” Parents may view the PCP as being very thorough and caring when they take the time to address the child’s BH needs. Some parents may need additional education regarding the potential role that PCPs may have in their child’s mental health. The authors conclude that the study supports the need for medical homes, where a child can receive treatment for both physical and BH all in one location.
Link to the article:
Taking 10 minutes to answer questions on an iPad before an annual visit may help adolescents and their pediatricians address sensitive mental health issues. A recent study published in the Journal of Adolescent Health looks at the use of a computerized screening program, DartScreen, and how it impacts what takes place during adolescents’ annual visit. Pediatricians are often pressed for time during the annual check-up because they are expected to screen for a wide range of medical and behavioral concerns. Inadequate time may contribute to the lack of screening and counseling regarding sensitive issues (e.g., depression) that has been shown for adolescents. A pre-visit screening questionnaire (or “screener”) may help primary care providers (PCPs) screen for a wide range of issues before the visit even begins, potentially freeing up time to focus on issues of particular concern. Studies have found that adolescents are more comfortable disclosing personal information to a computer than a person, indicating that a computerized screener may allow adolescents to more readily identify their physical and mental health concerns.
In this study, the authors compared 37 standard annual visits to 35 annual visits wherein adolescents completed a screener in the exam room prior to the visit. Adolescents aged 15-19 years, from two pediatric primary care clinics, who were scheduled for an annual visit, were eligible to participate. DartScreen took teens an average of 9.5 minutes to complete on an iPad and included questions about nutrition, exercise, school, safety, reproductive health, alcohol and substance use, and mental health. The PCP viewed the results of the screener at the start of the visit.
The study results showed that in the visits wherein the adolescents completed the pre-visit screener, adolescents offered up more psychosocial information and mental health was discussed more. One participating PCP noted: “It helped to pull out the issues. When you ask in person, you get monotone answers, but the screener helps them open up.” PCPs found the screener helpful for visit organization and efficiency. The findings suggest that using a pre-visit screener may:
- help PCPs complete a comprehensive annual visit,
- reduce the need to ask about each risk behavior during the visit, and
- free up time to allow adolescents to talk about mental health issues.
The authors’ conclude that “these findings suggest that use of a screener allows for a shift of focus to psychosocial topics, which are likely to be of more concern to teens given that adolescence is a time of significant social and emotional development.”
Link to article: http://www.jahonline.org/article/S1054-139X(14)00742-3/abstract
Evidence-Based Practice Guidelines for Cultural Competence in Behavioral Health Delivery
The Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Improvement Protocol (TIP) 59, Improving Cultural Competence, is a multidimensional framework that explains core elements of cultural competence in behavioral health delivery, as well as specific racial, ethnic, and cultural considerations. TIPs are evidence-based best practice guidelines published by SAMHSA to aid in their mission of reducing the impact of substance abuse and mental illness in America. The guidelines are developed through expert consensus by a multidisciplinary non-Federal panel, as well as relevant research findings, demonstration experience, and implementation requirements. TIPS are intended to provide guidance to clinicians, program administrators, and payers.
TIP 59 describes why cultural competence is important to behavioral health, explains how organizations and counselors can become culturally competent, and defines terms and concepts relating to cultural competence. Additionally, TIP 59 includes:
- core competencies for counselors and clinical staff,
- steps for culturally responsive evaluation and treatment planning,
- a guide to organizational cultural competence,
- a review of literature relating to specific cultural groups, and
- a description of drug cultures and the culture of recovery.
This TIP is intended to help counselors and organizations improve their cultural competence. Providing culturally responsive services is likely to result in better outcomes for clients with mental illness and/or substance use disorders.
This Treatment Improvement Protocols (TIP) is available at no cost at: http://store.samhsa.gov/shin/content/SMA14-4849/SMA14-4849.pdf
The Agency for Healthcare Research and Quality (AHRQ) has recently released two white papers related to quality improvement in primary care (PC).
As part of the effort to create a quality health care system in the United States, a variety of organizations, including many payers and delivery systems, are encouraging PC care organizations to use quality improvement (QI) initiatives to improve their performance. QI requires practices to:
- continually assess performance,
- plan changes in areas where improvements are warranted,
- monitor the effects of those changes, and
- refine as needed.
Use of QI by PC practices is an important component of efforts to improve population health. It will also result in improvement of the patient and provider experience and decrease the cost of care.
However, these activities are not routinely integrated into PC, and engaging in QI activities will be a new endeavor for most practices. Getting practice buy-in to undertake QI is challenging. This paper provides strategies for practice facilitators and the organizations that train and deploy them, based on the experiences of experts in the field.
Since QI activities are not routinely used in PC practices, using these strategies will be a new experience. This white paper was developed for practice facilitators and those who deploy them, and makes the following recommendations about strategies for facilitators to use in successfully engaging practices:
- assess the practice’s readiness to engage,
- develop tailored strategies appropriate for the practice, and
- maintain practice buy-in for meaningful and sustained engagement in QI efforts.
It is widely agreed that reshaping and revitalizing the PC system in the United States is critically important to achieving high quality, accessible, and efficient health care for all Americans. PC practices can improve their ability to deliver high quality care and improve patient outcomes through the effective use of health IT to facilitate QI.
While it is recognized that adaption of health IT by PC has been encouraged through recent health care policies and incentives, it is also recognized that significant barriers exist. These include:
- time and capital costs,
- lack of provider and staff training in data analysis and QI, and
- unfamiliarity with the potential benefits of using health IT for QI.
The authors of this white paper note there needs to be similar efforts “to encourage and expand use of health IT for QI.” They conclude by saying:
“With these barriers in mind, we recommend the following next steps for collaboration among PC practices, practice facilitators, IT developers, and decisionmakers to increase the use of health IT for QI in primary care:
- Share examples of exemplary uses and best practices to inspire and guide primary care practices seeking to create a culture that embraces using health IT for QI.
- Continue to develop and refine technology to produce high-functioning, interoperable health IT tools.
- Empower PC providers and staff with the necessary knowledge and skills to maximize the use of health IT for QI.
- Provide guidance and tools to help PC practices redesign processes and workflows to accommodate the effective use of health IT for QI.
- Expand the availability of financial and other transformation incentives and supports.
Although significant obstacles prevent many PC practices from using health IT for QI, practices in diverse settings have demonstrated it is possible and pays off in improved processes of care and patient outcomes. Additional support for PC practices seeking to make these transformations—in the form of payment reforms and technical assistance—will help more practices adopt a culture of commitment to using health IT for continuous QI and ultimately ensure patients are receiving the best possible primary care.”