Several payment reform initiatives are shaping the world of behavioral health and primary care integration. A recent blog post by the National Academy for State Health Policy (NASHP) provided an overview of state strategies being developed and implemented for integrating behavioral health and primary care. Notably, a number of Medicaid programs now allow Federally Qualified Health Centers (FQHCs) to bill for behavioral health and primary care services that are provided on the same business day. The SAMHSA-HRSA Center for Integrated Health Solutions website provides information on policies, billing codes, and procedures regarding these changes in all 50 states. Universal changes to state-level Medicaid payment policies are encouraged to remove barriers related to the provision of integrated behavioral health and primary care.
The Medicare program has also examined payment reform initiatives as related to FQHCs. As of October 2014, Medicare’s new Prospective Payment System for FQHCs allows for reimbursement for same-day behavioral health and primary care services.
For information on NASHP and their work on policy and payment issues see NASHP.
More information about government-sponsored insurance and payment reform initiatives surrounding behavioral health and primary care can be found at SAMHSA.
Major depression affects women twice as often as men over the lifetime. Women’s highest rates of depression occur during reproductive and menopausal transitions. Additionally, more than one-third of obstetrics-gynecology (OB/GYN) patients use their OB/GYN physician as their primary care provider, particularly those with limited income and limited or no health insurance. However, OB/GYN physicians often have less training in depression than other primary care physicians.
In addition, markers of social disadvantage (lack of health insurance, low income, unemployment, lower educational attainment, and single parenthood) are related to higher rates of depression and anxiety, as well as more persistent depression. The Depression Among Women Now (DAWN) study was conducted to determine whether collaborative depression care in an OB/GYN setting was as effective in treating socially disadvantaged women with no health insurance or public coverage as it was in treating women with commercial insurance.
The DAWN intervention included hiring a social worker at two different OB/GYN clinics to assist in overcoming barriers to care, such as lack of transportation and housing issues. Social workers provided an initial engagement session that has been shown to improve rates of mental health follow-up care, as well as follow-ups by phone or in person every 1 to 2 weeks for 12 months. During weekly meetings, a social worker, a psychiatrist, and an OB/GYN physician recommended medication and behavioral treatment plans.. One of the clinics was a county-hospital-based clinic that mostly treated a socially disadvantaged population, and the other was a university-based OB/GYN clinic that treated a mixed socioeconomic population.
The DAWN intervention was found to be more effective than usual care for patients with no health insurance or public coverage. Intervention patients had improvements in depression treatment, as well as improvements in depressive symptoms and functioning during the 18 months following the 12-month-long intervention. Additionally, results were similar for both clinics, despite differences in the socioeconomic status of their patients.
Follow The Academy Portal in November for additional information on the use of integrated behavioral health care in the OB/GYN setting.
For more information, refer to:
Cardiovascular disease (CVD) is the leading cause of death in the United States. All adults, regardless of risk for cardiovascular disease, can benefit from better nutrition, improved eating behaviors, and more physical activity. The U.S. Preventive Services Task Force (USPSTF) recently updated its 2003 recommendation on dietary counseling for adults with risk factors for cardiovascular disease (CVD), and concluded with moderate certainty that intensive behavioral counseling interventions to promote a healthful diet and physical activity have a moderate net benefit in overweight or obese adults who are at increased risk for CVD.
Based on this systematic review conducted by the U.S. Preventive Services Task Force (USPTF), low-intensity behavioral counseling consisted of only mailed materials or 1 to 2 sessions with a primary care provider or other trained person. The low-intensity counseling did not have an impact on behavioral or intermediate health outcomes. Medium-intensity behavioral counseling involved 3 to 24 phone sessions or 1 to 8 in-person sessions. High-intensity behavioral counseling consisted of 4 to 20 in-person group sessions. This medium- to high-intensity style of behavioral counseling was the only intervention to report sustained benefits beyond 12 months.
This evidence demonstrates the effectiveness of medium- to high-intensity behavioral counseling in making small but important changes in health behavior outcomes. Even small improvements in lipid levels, blood pressure, glycemic control, and weight (all known risk factors for CVD) can decrease risk of CVD. Effective counseling sessions may be provided to patients in primary care settings, or in other settings as referred by a primary care physician. Primary care providers and/or behavioral health specialists can also refer patients to community-based resources to improve the delivery of these services.
The resulting USPSTF recommendation (Level B) is to offer overweight or obese adults with additional CVD risk factors the opportunity for intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention. The population this recommendation applies to is adults aged 18 years or older in primary care settings who are overweight or obese and have known CVD risk factors (hypertension, dyslipidemia, impaired fasting glucose, or the metabolic syndrome).
Complete information on this review is at: Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors
Access to the full article published in the Annals of Internal Medicine is found at: http://www.ncbi.nlm.nih.gov/pubmed/25155419
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 .