Behavioral Health and Primary Care Integration—The New York State Perspective

Date: 

12/05/2013

As New York State sees it, integration “opens the door to collaboration, timely care, improved quality, and parity for general medical and behavioral illnesses—and closes the door on disconnected treatment that is divisive, ineffective, and inaccessible.” In order to move toward integrated health care and to achieve triple aim outcomes, New York has implemented several statewide policy and program initiatives. First, New York began restructuring its Medicaid program after examining data that revealed that more than half of the 800,000 individuals identified as the most costly, had a primary or secondary behavioral health diagnosis. These findings supported the ensuing Medicaid reform initiatives and emphasized the urgency of integrating general medical and behavioral health (mental and addiction) services into a comprehensive service delivery system. The State’s Medicaid reform encompasses financing, licensing, and regulatory policies to emphasize integration.

In addition, New York has put in place several other clinical quality improvement efforts to move toward greater primary care and behavioral health integration, including improved standards for monitoring medical conditions in behavioral health settings and incentives for collaboration between medical and behavioral health providers. In 2007, the New York State Office of Mental Health (OMH), along with the Office of Alcoholism and Substance Abuse Services and the New York State Health Foundation, began with the integration of mental health and substance abuse treatment for people with co-occurring disorders and then transitioned to the integration and coordination of mental health and primary care. These agencies eliminated “financial and regulatory barriers to integrated treatment” and provided funding for establishment of a Center for Excellence in Integrated Care that could “provide hands-on assistance in implementing best practices in at least half of the state’s 1,200 mental health and substance abuse treatment clinics.” Lloyd Sederer, M.D., medical director of the New York State Office of Mental Health (OMH), says “the idea is that for patients there will be no wrong door for them to enter to get the health care they need, whether they are seen at a primary care or a behavioral health clinic.”

Sederer credits NIAC member Mike Hogan, former NY State Mental Health Commissioner, for encouraging him “to expand statewide the primary care initiatives he had helped start in New York City, when he was executive deputy commissioner for mental hygiene in the City’s Department of Health and Mental Hygiene.” For example, under a new initiative in 2005, primary care practices began “to use the PHQ-9 on a routine basis to screen for and then treat depression.” Moreover, last year, OMH collaborated with the NY State Department of Health to implement in primary care training clinics at 20 academic medical centers the model of collaborative care developed by NIAC member, Jürgen Unützer and colleague, Wayne Katon. This “initiative will train primary care providers to screen for and treat depression, using care managers to engage and educate individuals, and psychiatrists will be available to consult with care managers and primary care doctors regarding individuals whose depression-assessment scores show little improvement.” It will also [introduce] a new generation of physician trainees to the principles of collaborative care.

OMH now “licenses and oversees mental health services provided to more than 700,000 individuals each year by more than 100 not-for-profit hospitals, 80 assertive community treatment teams, and 250 agencies offering clinic and other ambulatory programs. It also “operates 24 state psychiatric hospitals and more than 90 outpatient clinics.” According to Sederer and colleagues, [the state] initiatives  “…were implemented to improve access to health and wellness-oriented services, redesign managed care programs to improve engagement and retention of high-need individuals, and raise the bar on quality while lowering costs. Taken as a whole, these initiatives represent a 21st-century transformation of a state mental health authority into an accountable and more fully integrated public health delivery system.

Read more about these initiatives at:  http://ps.psychiatryonline.org/data/Journals/PSS/927485/828.pdf and http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=1761301