A broad gap exists between behavioral health (BH) needs of low-income Californians and BH treatment, a recent report finds. The report from Blue Shield of California Foundation discusses the results of a survey, which measured low-income Californians self-reported needs for and barriers to BH assistance. The results found that 3 out of 10 survey respondents had a time in the past year when they have felt the need to talk with a health care professional about their BH; however, only half of these individuals actually talked with one about these issues. Barriers identified included stigma, cultural, and language barriers, as well as not knowing where to get help. The findings also highlight a mismatch between patient interest in receiving Services at a primary care (PC) facility and current availability of these services, with three-quarters indicating that it was “highly important” that their facilities provide BH services, but only half reporting that these services were available. The survey results demonstrated strong support for interest in integrated care among low-income Californians, with the majority indicating a strong preference for receiving BH services in the same setting as their PC. Sixty percent reported a preference for discussing BH issues with a professional at their PC facility, rather than off site.
The report provides several recommendations for how to bridge the gap between BH needs and services based on the survey results. A few of these recommendations include:
- Integrating BC specialists into PC practices;
- Making patients more aware of BH resources; and
- Having health care providers routinely ask patients about their emotional well-being.
The authors explain that:
“By inviting patients to discuss their behavioral health needs within the primary care setting, primary care providers may vastly improve the chances that their patients will seek help. By strengthening and deepening their relationships with their patients, providers and healthcare facilities have the potential to dramatically enhance health treatment for low-income Californians.”
The Blue Shield of California Foundation research report findings add additional support to previous research on the benefits of integrated BH services in PC settings, particularly as a way to reduce stigma and increase ease of access by providing care within a PC clinic.
Read the Blue Shield of California Foundation report:
View the Health Affairs article on bridging the gap:
The Collaborative Family Healthcare Association (CFHA) posted a series of four stories on their blog that highlight developments in the field of behavioral health and primary care integration. The series covers a wide range of topics, including health care policy, delivery, and financing. Multiple members of the National Integration Academy Council (NIAC) and AHRQ Academy Team are featured in the series.
In the first blog post, “The Wild West and Healthcare Innovation: Colorado’s Frontier Legacy Continues,” Benjamin Miller, PsyD, (Academy Principal Investigator), describes a State Innovation Model grant that will allow Colorado to integrate behavioral health into 400 primary care practices through payment.
Neil Korsen, MD, MSc, (NIAC), and Becky Boober, PhD, co-authored the second blog post, which details some of the many efforts being made across Maine to advance integration of primary care and behavioral health. Almost 50 percent of primary care practices in Maine offer some level of integration largely as a result of two organizations, the Maine Health Access Foundation and Maine Quality Counts.
Christine Borst, PhD, and Cathy Hudgins, PhD, LMFT, relay their experiences with integration in North Carolina in the third blog post of the series. Borst describes the Center of Excellence for Integrated Care (COE), a program of the North Carolina Foundation for Advance Health Programs. COE is committed to helping develop and advance integrated care across the state by systematic training, assistance, and capacity-building to contracted entities. Hudgins lists a number of federally funded programs for integration in North Carolina. Both Borst and Hudgins contributed to a list of the top 10 lessons they learned as “practice transformationists.”
The final blog post outlines the experiences of Robin Henderson, PsyD, leading up to the passage of Oregon Senate Bill 832, which defines integrated care, behavioral health homes, and behavioral health clinicians. Henderson acknowledges that CJ Peek (NIAC) and Benjamin Miller provided “invaluable editorial guidance” in defining integrated care through their work for the AHRQ Academy. The new law will remove some of the financial and regulatory barriers that previously hindered provision of integrated primary care and behavioral health in Oregon.
Access the CFHA Blog: http://www.cfha.net/blogpost/689173/CFHA-Blog
A recent Journal of the American Medical Association Viewpoint article argues that developing quality measures for assessing and rewarding high quality integrated behavioral health care could promote widespread adoption of an integrated care model. Patients with behavioral health issues, such as serious mental illness and substance abuse, use more medical resources than other patients, particularly when these patients have comorbid medical conditions. Effective models of care exist that integrate physical and behavioral health services and have demonstrated improvements in patient outcomes and cost reduction. One model discussed in the article is collaborative care model, which has demonstrated cost savings in low-income, high-risk patient populations compared to traditional models. Despite cost-saving and patient outcome benefits associated with integration, these models have yet to be implemented on a large scale. One barrier to widespread implementation is the lack of systematic incentives, payment, and improvement strategies designed to reinforce best practices and outcomes for integrated care patients – key to this process is the development of valid quality measures. The article’s authors, Matthew L. Goldman, MD, MS, Brigitta Spaeth-Rublee, MA, and Harold Alan Pincus, MD, from Columbia University Medical Center, Department of Psychiatry, build the case that “developing and validating a set of robust quality measures that targets this high-cost/high-need patient population and is tied to new payment mechanisms can play a powerful role to encourage more cost-effective care.” Current quality measures tend to be rather limited in scope and do not address behavioral and physical health integration. The authors conclude that best practice and outcomes measures for integrated care “can increase accountability across health care settings, diminish disincentives to serve and treat […] complex patients, broaden dissemination of research-proven models that improve patient outcomes and enhance the efficiency of the health care system as a whole.”
Read the Viewpoint article:
For additional information on collaborative care models, view the following brief:
Integration of substance use disorder (SUD) treatment services are not getting adequate attention in health care settings, a new white paper suggests. The Addiction Technology Transfer Center (ATTC) Network released “Integrating Substance Use Disorder and Health Care Services in an Era of Health Care Reform” in March 2015. Current momentum for the integration of SUD and health care services stems from policy changes resulting from health care reform, as well as from growing evidence demonstrating improvements in patient outcomes form integrated services. Research shows that SUDs are common among patients in health care settings and should be treated in manner similar to other common diseases. This ATTC Network paper emphasizes the need for better integration of SUD and health care services and describes a variety of effective models, evidence-based interventions, and implementation strategies for treating SUDs within health care settings. The paper also highlights the work of the ATTC Network. The ATTC Network is the Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) program designed to promote both workforce development and implementation of evidence-based SUD interventions. “The Network is an essential resource as states, providers, and the SUD treatment workforce embark on change under health care reform.” One such resource discussed was The ATTC/NIATx Network of Practice, an online learning community with SUD integration implementation instructions and additional resources to assist providers. The authors conclude that 1) there is a need for better integration of SUD and health care services; 2) there is an array of effect approaches for integration including models, interventions, and implementation strategies; and 3) SAMSHA’s ATTC Network is a key resource for guiding the SUD and health care services integration process.
Link to the white paper:
Link to The ATTC/NIATx Network of Practice:
Vikram Patel, PhD, delivered a TED talk at TEDGlobal2012 encouraging the training of laypeople to deliver mental health services to help meet the worldwide mental health workforce shortage. Patel, trained as a psychiatrist in Britain, highlighted the gap between mental health needs and service provision for people with mental health problems — “the vast majority of these individuals do not receive the care that can vastly improve their lives.” This is a major problem in developed countries and is an even greater problem in developing countries. Patel explains that there is a gulf between the knowledge we have about mental health and what to do with that knowledge. In developing countries, where mental health professional are in short supply, alternative resources may need to be considered. Three experiments are highlighted in which lay persons were trained to deliver psychotherapy with positive outcomes. Patel makes the case that “in order for us to achieve health for all, we will have to involve all in that particular journey.”
View the TED Talk:
Read the associated blog post:
The Affordable Care Act (ACA) was signed into law 5 years ago. In the time since its passage, the ACA has increased the number of Americans with health insurance, increased access to affordable health care, and may be contributing to slowing the rate of increase in health care spending.1 In addition, the ACA has transformed the delivery of health care,1 including changes that advance primary care and behavioral health integration. Among the post-ACA initiatives enabling opportunities for transformation through the integration of primary care and behavioral health are:
- State Innovation Models (SIMs) – Provides Federal dollars and technical assistance to help states and private payers provide better care at lower costs
- State Plan Amendments (SPA) – Sixteen states have agreements with the Federal Government that relate to the integration of primary care and behavioral health within Medicaid and the Children's Health Insurance Program CHIP administration
- Independence at Home Demonstration (IAH) – An Innovation Center program to test the effectiveness of delivering team-based comprehensive primary care services at home to high-need Medicare beneficiaries
- Medicaid Innovation Accelerator Program (IAP) – Technical assistance program launched that supports states in accelerating payment and delivery system reforms for Medicaid beneficiaries relating to issues such as substance use disorders and mental and physical health integration
- Comprehensive Primary Care Initiative (CPCI) – A program that supports innovative health care payment and organization models, including some that focus on care-coordination and chronic disease management
- Multi-Payer Advance Primary Care Practice Demonstration (MAPCP) – A demonstration program that provides a monthly care management fee for Medicaid beneficiaries who receive care from patient-centered medical homes.
For additional information, view the following resources:
- ACA Payment and Delivery Reform Systems at 5 Years – An issue brief from the Commonwealth fund
- Summary of Select Affordable Care Act Payment and Delivery System Reform Provisions – A supplemental table describing ACA reforms from the Commonwealth Fund
- The Affordable Care Act at 5 Years – A New England Journal of Medicine article
- Healthcare Integration in the Era of the Affordable Care Act – A report from the Association for Behavioral Health and Wellness
1Blumenthal D, Abrams M, Nuzum R. The Affordable Care Act at 5 Years. N Engl J of Med. 2015 Jun 18; 372(25): 2451-8. PMID: 25946142
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:
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:
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:
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