Integrated Primary Care and the Opioid Crisis
The comparative flood of new users of opioid medication and heroin in the population has led to a crisis. That it is a crisis is agreed to by politicians, medical professionals, substance abuse professionals, and the public in general. I am told that the Chinese character for “crisis” is made up of a combination of the characters for “danger” and “opportunity.” I recently heard a report from Beth Tanzman, the Assistant Director of the Vermont Blueprint for Health that Vermont has taken the opportunity presented by this danger to respond with a distinctive approach to creating integrated behavioral health in primary care. Instead of small changes in payment or regulation, they simply funded salaries for behavioral health clinicians in primary care. The chief duty of these clinicians is to address substance abuse concerns, but they are inevitably addressing a broader array of behavioral concerns.
I think there are two important points that this example brings to mind.
1. Whether the impetus for adding behavioral health in primary care is to treat people with serious depression, to provide better care for people with trauma histories, to attempt to intervene before people are involved in the criminal justice system, or to address serious substance abuse is a choice based on administrative and funding opportunity, because as a population THEY ARE MOSTLY THE SAME PEOPLE.
2. If you only target serious substance abuse with your behavioral health resources, you are seeking to intervene in the process too far downstream. Unless you are offering behavioral alternatives in chronic pain therapy, so that physicians have some way of helping their pain patients other than opioid pain medications, you are not helping stem the tide of new addicts.
And, today only, you get 50% more important points than promised:
3. If you define the role of a behavioral health clinician that you put in a primary care practice (a “general medical setting”) as only addressing substance abuse, you make your program fall under the strictures of 42 CFR (the Federal statute regulating the exchange of information about a patient’s substance abuse care). The clinician and physician cannot exchange information without further releases. If you define the role as a behavioral health generalist, though they may do a good deal of work with substance abuse, 42 CFR does not apply. (Your state may have other regulations that do apply.)
The Collaborative Family Healthcare Association (CFHA) blog recently reprinted a post by Dr. Alexander Blount. Dr. Blount looks back to provide a brief review of the history of integration. Of the current state of integration he says:
“We have to keep reminding each other not to ask does integration work? Does the PCMH work? Can integration save money? We have to ask what form of integration works in what context? How are they doing the PCMH in what regulatory and payment environment so that it works? What sort of integration or care management program targeted at which patients, accounted [for] by looking at what parts of the system works financially?”
He ends by looking to the future, and focusing us on the real point, saying:
“Our current success and rapid development is great, but it is a movement that is much bigger than all of the pioneers now. We have to keep reminding ourselves that integrated primary care, or integrated behavioral health, or whatever else we call it, is not important. Better care for patients is important. If we keep our eyes always on that, integration will evolve and be durable for a long time.”
Achieving integrated care is complex because of different payment systems, staffing, and other challenges. Roger Kathol, M.D., a leading expert on primary care and behavioral health integration, provides his perspective on these problems as well as solutions in an interview with the Academy.
Behavioral health is the only health care discipline that has a completely different payment system for services. “The way payment is provided creates a challenge for primary care settings to bill for behavioral health services because they are billed to separate agencies, using separate coding and billing processes. This payment method needs to change so practices working on integration can become financially sustainable.”
Furthermore, “the majority of behavioral health payments come from public programs, which do not pay at a level that is commensurate with the type of cost and level of services that are delivered.” Dr. Kathol proposes consolidating the different payment systems for medical and mental health services into one integrated payment system.
Another challenge is staffing integrated clinics. “The number of behavioral health personnel that want to work or adapt their work process to (function) in a primary care setting and the number of behavioral health staff that are formally trained in primary care is limited.” A related issue is the limited number of primary care clinics with additional space to accommodate behavioral health providers seeing patients.
Other factors that influence whether integration is successful are quality control and accountability. To determine whether patients with comorbid mental and medical conditions are receiving effective integrated health care, Dr. Kathol recommends measuring improvements in these areas:
- The degree to which the patient is stabilized,
- Impairment due to management of the patient’s disease or disability,
- Social functioning (e.g., volunteering, hobbies, or other activities),
- Total health care costs, and
- Quality of life and greater patient satisfaction with care.
Dr. Kathol sees effective integration of services as a system in which both disciplines have “joint accountability for medical and mental health outcomes and not just outcomes in their disciplines.” The goal is to have a “treatment team where practitioners have the capability to change outcomes – this means access to specialists in both medical and behavioral health disciplines with the kinds of qualifications that allow them to provide services that are evidence based.”
Health care systems often need transformation to accommodate integrated efforts, Dr. Kathol concludes. “Both behavioral health and primary care providers may need to redefine their clinical approaches and financial models for the U.S. health care system to move to a higher standard and integrated level of care.”
For more information:
Kathol RG, Butler M, McAlpine DD, et al. Barriers to physical and mental condition integrated service delivery. Psychosom Med 2010;72(6):511-8. https://www.ncbi.nlm.nih.gov/pubmed/20498293. Accessed June 2, 2017.
Mauch D, Kautz C, Smith S. Reimbursement of mental health services in primary care settings. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; 2008. HHS Pub. No. SMA-08-4324. https://www.integration.samhsa.gov/Reimbursement_of_Mental_Health_Services_
in_Primary_Care_Settings.pdf (PDF - 1.64 MB). Accessed June 2, 2017.
According to Dr. Parinda Khatri, Director of Integrated Care at Cherokee Health Systems, Cherokee has an embedded behavioral health team in the primary care practice. The behavioral health team provides consultation, assessment, and intervention to address a number of issues ranging from traditional mental health (e.g., depression, anxiety, and diagnostic clarification) to health psychology issues (e.g., self-management of diabetes, asthma, healthy diet, smoking cessation programs for teenagers). In addition to the behavioral health team, a specialty mental health clinic is available. The specialty mental health clinic provides psychiatric consults, case management, therapy, and followups as needed using face-to-face patient care as well as telemedicine.
One unique aspect of the Cherokee model is that the specialty mental health and the primary care behavioral health team work closely together to coordinate care. This approach allows them to refer patients back and forth between specialty mental health and primary care behavioral health depending on the patient’s needs.
However, Dr. Khatri points out that this system took years to create, and barriers still remain. She outlined three obstacles often preventing others from integrating behavioral health into their clinical programs:
- Financing system: The current financing system is fragmented and archaic. The fee-for-service environment promotes disintegration and inhibits collaboration among providers.
- Workforce: The workforce is not prepared for integration. There is a lack of providers with the training needed to function in primary care settings since providers are typically trained in silos rather than team-based approaches.
- Operational: Currently, there are different ideas of what integration is and what the model is, which creates confusion and interferes with the integration process since people are working on different goals and ideas of what integration should be.
Despite these barriers, Dr. Khatri is optimistic about the future: “The coming years are going to be very exciting. The field will be moving to the next step, which includes (but is not limited to) building and better defining the model of mental health and primary care integration. In the following years, we will have the findings from the ongoing research carried out by pioneers in the field, which will allow for identifying which components are effective, as well as making more evidence-based interventions available for primary care settings.”
For more information:
Hunter CL, Goodie JL. Operational and clinical components for integrated-collaborative behavioral healthcare in the patient-centered medical home. Fam Syst Health 2010;28(4);308-21.
As behavioral health services in primary care settings become more widely implemented across the country, the need for skilled providers in this area grows. In response to this demand, initiatives to cross-train behavioral health providers are underway. The goal of these training programs is to ensure these providers can successfully integrate their various disciplines into the primary care field.
“Training for behavioral health providers in primary care is in the early stages of developing an infrastructure. There are a few training programs or tracks specifically for work in primary care, but not many,” says Dr. Alexander Blount, a Professor of Family Medicine and Psychiatry at the University of Massachusetts Medical School and the Director of Behavioral Science for the Department of Family Medicine and Community Health.
Why the Gap in Training Exists
There are several barriers to bringing behavioral health workers into primary care. Many of the obstacles are rooted in current academic training.
Current Curriculum Training
“One obstacle is that there is no curriculum in undergraduate or graduate psychology in primary care,” says Dr. Blount. He has taught the psychosocial aspects of primary care to Family Medicine residents and directed his department's 2-year Fellowship in Primary Care Psychology for years. As Program Director of the University’s Certificate Program in Primary Care Behavioral Health, Dr. Blount helps train behavioral health clinicians from all over the country on how to work successfully in primary care.
To illustrate the drawbacks of the current curriculum training, Dr. Blount uses the psychology field as an example. Psychologists may have training to address a variety of health conditions but, as Dr. Blount points out, “their training may be health psychology, but it is not primary care and there is very little awareness in academic psychology that there is anything missing.” Further, Dr. Blount says, “health psychology is essentially a specialty topic that works in specialty settings and tends not to understand the differences of primary care. They (psychologists) miss the curriculum, which creates a lack of urgency on the part of health-oriented academia.”
Focus on Politics Instead of Workplace Tools
Also, in academia, there is a greater focus on the politics and needs of that discipline, rather than on the workplace. “People commonly say that they received training, but there wasn’t a job to follow. This is one area where there really are jobs, and there will be more jobs, but it has not yet entered the consciousness of those who design programs in academia. People don’t know what they don’t know, so somebody who has not been through the certificate program may ask for a talk to get a program started and doesn’t have a sense of the body of knowledge and experience needed,” Dr.Blount says.
Training Solutions and Resources
Recognizing the importance of primary care for a redesigned health care system, Dr. Blount highlights the need for generalizable skills. “Primary care is an area in which skills are modular, not disciplinary, so social workers, psychologists, nurses, anybody could be successful in primary care if they get the specific set of skills. People always say, ‘Do you want a social worker or do you want a psychologist for this?’ and I say ‘Which social worker, which psychologist?’ because nobody is prepared just because they have the right discipline. There isn’t a right discipline.”
The certificate program Dr. Blount directs was created in response to some of the problems he saw when watching behavioral health providers start to work in primary care.
“Simply learning on the job results in a lot of failures and half-successes because if behavioral health providers act in primary care the way they acted in the mental health center, in terms of the way they see patients and relate to their colleagues, it is going to fail. One of the problems with the usual way of developing workforce is that it is an academic area and it tends to result in reports rather than in new workers. There are a number of States and the Federal Government that consider this a very concerning and urgent issue.”
For primary care and behavioral health integration to become a reality, there must be a better trained workforce that is prepared for a setting that is unlike the one in which they were trained to work.
For more information:
Blount A, Miller BF. Addressing the workforce crisis in integrated primary care. J Psychol Med Settings 2009;16:113-9.
Blount AS, DeGirolamo S, Mariani K. Training the collaborative care practitioners of the future. Fam Syst Health. 2006;24:111-9.
In this interview with the Agency for Healthcare Research and Quality (AHRQ) Innovations Exchange Team, Benjamin Miller, Psy.D, Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine, discusses the topic of integration of behavioral health in primary care. Integrated primary care helps improve the detection and treatment of mental health conditions in patients in primary care settings and, as Dr. Miller explains, can save money and improve health outcomes.
Dr. Miller provides two examples of exemplary models of integrated primary care that embed behavioral health providers into the primary care team to actively and more immediately address the behavioral health needs of their patients. He also mentions several efforts to further advance integrated primary care, such as research examining the effectiveness of integration, as well as the AHRQ Academy, for which Dr. Miller is the principal investigator.
Dr. Miller further explains how academic training in disciplines such as internal medicine and family practice helps advance integrated primary care by including more training in behavioral health and team-based care. Despite these efforts, Dr. Miller says there are still several barriers to integrated primary care, such as silos in professional training and in the health care payment system. Dr. Miller asserts that we should continue to work to change the clinical, operational, and financial realms of the system for better health care quality and outcomes.
He says, “Integrated primary care is one of the most significant ways the health care system can achieve the goals of the 'Triple Aim’ to decrease costs, improve outcomes, and enhance patient experiences.”
In his May 2013 policy brief on the Collaborative Care Model, NIAC member Dr. Jürgen Unützer and colleagues reveal that rates of depression are 20 percent in the Medicaid population and 23 percent in the Medicaid-Medicare dually eligible population. In addition, Medicaid patients with major depression and a chronic condition (e.g., diabetes) have more than twice the overall health care costs than those without depression.
These Medicaid enrollees with comorbid mental health conditions receive poorer quality of care for their medical conditions and have mortality rates four times as high as those of the general population. A large majority of adults with these common mental health disorders receive care from primary care practices as opposed to a mental health care specialist. They prefer that primary care and mental health providers work together to treat medical and behavioral health needs.
Health homes are one way States can both “integrate primary and mental health care and pay for the essential components of enhanced care management and care coordination required for effective integration,” particularly for the Medicaid population. According to Section 2703 of the Affordable Care Act of 2010 (ACA), the Medicaid Health Home State Plan Option offers a mechanism for coordinating primary, acute, behavioral, and long-term and social service needs for Medicaid beneficiaries who have at least two chronic conditions, have one chronic condition and are at risk for another, or have a serious mental illness. Associated providers must meet all Federal and State qualifications to serve as health homes and must deliver a specific set of services across which improved integration of primary and behavioral health care delivery is an important desired outcome.
While there have been efforts to improve the treatment of common mental health disorders in primary care, some approaches have not improved patient outcomes alone or in combination, although they might be necessary parts of effective interventions. These include:
- Education of primary care providers (PCPs),
- Development of treatment guidelines and referral to mental health specialty care,
- Co-location of mental health specialists within primary care clinics, and Telephonic disease management programs.
However, evidence shows the Collaborative Care Model can effectively implement integrated care and do so under the authority of health homes. This model consists of care provided by a collaborative team that includes a PCP (i.e., a family physician, internist, nurse practitioner, or physician assistant), case management staff (i.e., nurses, clinical social workers, or psychologists), and a psychiatric consultant.
In terms of clinical practice, collaborative care programs follow measurement-based care, treatment-to-target, stepped care, and other aspects of the chronic illness care model where each patient’s progress is tracked using validated clinical rating scales (e.g., PHQ-9 for depression). Treatment is systematically adjusted or stepped up where initial adjustments are made by the primary care team with input from the psychiatric consultant. Patients who do not respond to treatment, who have an acute crisis, or who seek referral are referred to mental health specialty care. However, only a small number of patients request or are referred to specialty care.
Collaborative care has consistently demonstrated higher effectiveness than usual for different populations such as ethnic minority groups, insured and uninsured/safety-net patients, and for different mental health conditions such as depression, anxiety disorders, schizophrenia, and bipolar disorder. For instance, the IMPACT (Improving Mood -- Promoting Access to Collaborative Treatment) study, the largest trial of collaborative care to date, showed collaborative care was effective for depressed adolescents, depressed cancer patients, and diabetics, including low-income Spanish speaking patients.
In addition, IMPACT participants were more than twice as likely as those with usual care to have substantial improvement in their depression over 12 months. They also experienced less physical pain, better social and physical functioning, and better overall quality of life than patients in usual care. Patients and PCPs strongly endorsed this collaborative care model and it is cited as one of only a few studies demonstrating that patient-centered medical home (PCMH) models can achieve the Triple Aim to improve health, improve quality of care, and reduce costs. Finally, collaborative care also reduces many of these negative economic effects of depression, which, in turn, results in improved personal income, employment, and other workplace outcomes.
Implementing effective collaborative care in safety-net programs might require major change and thus create barriers such as lack of trained staff or lack of effective disease management registries. However, many large health organizations, such as the Mental Health Integration Program (MHIP) in Washington State and CareOregon, have put into practice large-scale collaborative care programs demonstrating “the applicability of the model to safety-net providers and the patients they serve.” The AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington recently convened a group of national experts to produce the “,” a consensus statement on core principles and specific functions needed to implement effective collaborative care programs.
Conveniently, the Collaborative Care Model is an approach to integration that can be expanded to address a broader range of beneficiary needs. For example, Minnesota’s DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction) program used the key components of collaborative care to develop fuller PCMHs. Moreover, the new health homes service promotes the opportunity to adapt effective evidence-based models of care that define health home services and provider qualifications. Thus, States can use this Collaborative Care Model “as a building block for health homes and other initiatives that aim to better integrate care for Medicaid beneficiaries with chronic physical and behavioral health needs.”
In this webinar, Benjamin Miller, Psy.D., and Shandra Brown Levey, Ph.D., from the University of Colorado, Denver, speak about breaking down the separation of primary care and mental health services to improve the quality, cost, and coordination of care. Dr. Miller and Dr. Brown Levey discuss efforts to turn best practices into national policy, as well as the State of Colorado's model for integrating mental health, behavioral health, substance use, and primary care. Dr. Miller is also Principal Investigator for The Academy for Integrating Behavioral Health and Primary Care.
Access the webinar recording.
Dr. Kavita Patel discusses integration within the context of current health care policy in her webinar, “The State of Health Care Policy.” Dr. Patel touches upon the many programs in the Affordable Care Act that may facilitate more integrated care, including Health Homes and Accountable Care Organizations (ACOs). The California Mental Health Services Authority, Collaborative Family Healthcare Association, the AHRQ Academy, and the Office of Integrated Healthcare Research and Policy in the Department of Family Medicine at the University of Colorado School of Medicine jointly presented this webinar.
Access the original State of Health Care Policy webinar.
In their article titled “Fostering Sustainable, Integrated Medical and Behavioral Health Services in Medical Settings,” NIAC member, Roger Kathol, MD, CPE and Ron Manderscheid, PhD, propose an alternative approach to integrating behavioral health and primary care services. Unfortunately, “untreated behavioral health conditions in primary care settings are associated with treatment nonresponse, illness persistence, higher medical illness complication rates, disability, increased health care service use, higher health care costs, and premature death”. Moreover, “in 2012, the annual additional cost of medical care for the nearly 41 million Americans with behavioral health conditions was [about] $290 billion.”
The U.S. Department of Health and Human Services; national managed health care organizations; and state, county, and local governments have tried for nearly a decade to encourage the Integration of behavioral health into primary care. Unfortunately, three limiting factors affect them. First, it is perceived that a separate behavioral health care system is needed to care for those who have “difficulties with cognitions, emotions and behaviors.” In addition, it is believed that separate payment systems are required “to maximize value and ensure adequate control of and support for delivery of behavioral health services.” Last, due to stigma surrounding behavioral health conditions and treatments, it is “difficult for representatives of behavioral health and primary and specialty medical care to have the necessary dialogue that would facilitate service integration.”
Due to these limitations, current integrated care delivery models are “proceeding along several distinct and often uneven trajectories.” The “traditional and most commonly used” model for patients with comorbid physical and behavioral health conditions is cross-referral between behavioral health specialists and medical practitioners, both of whom typically work in 2 separate, noncommunicating service locations.” Although this model is simple, it is not very effective as most referred patients never make it to their referral sites. The bidirectional model was introduced to improve upon the cross-referral model. Under this approach, patients presumably “fall into one of two largely non-overlapping groups: patients with primary medical conditions but occasional behavioral health conditions and those with primary behavioral health conditions but occasional medical conditions.” However, patients with mild to severe behavioral health conditions “would be better served if behavioral health care services were available as a standard health benefit in patient-centered health homes.”
Drs. Manderscheid and Kathol offer an alternative model of integration that “should maximize health and function for patients with concurrent medical and behavioral conditions, regardless of service location.” Under their collaborative care approach, behavioral health is “viewed as a part of total health” in the patient-centered health home where “90% of patients with behavioral health conditions [are] seen in primary and specialty medical settings in which behavioral health is a core part of delivered services” and “the remaining 10% [is] seen in an embedded specialty behavioral sector that, like other medical specialty settings, has ready access to collaborative general medical services for its patients when needed.”
Including behavioral health professionals in patient-centered health homes will require considerable planning for best set up and delivery. Behavioral health specialists will need to leverage opportunities to “offer necessary evidence-based specialty services [that] could facilitate better outcomes” for people with untreated behavioral health conditions and comorbidities. From the standpoint of behavioral health specialty settings, every patient would have a lead behavioral health provider and should also have a collaborating primary care physician” that together would “function well as a team in providing preventive, acute, and long-term complex medical care along with BH care.” Additionally, an integrated care coordinator would be responsible for patients’ medical needs, social support (including housing, job support, and social network development), and health system logistics (for example, transportation or poor communication among providers).” They would “have good relations with the patient’s primary care physicians and clinical backup from a psychiatrist” and would thus “help patients overcome clinical and nonclinical barriers to improvement.”
Drs. Manderscheid and Kathol assert that their model of care cannot exist if there are separate payments for behavioral health and medical care. This separation is “the single most common factor that [prevents] integrated program initiation, development, and sustainability.” Thus, they recommend that medical and BH professionals demand that medical and behavioral benefits be combined in all provider contracts and that all health services be paid from a single budget by using common procedure.” If payment reform is not included in clinical reform, 60% of patients with untreated behavioral health conditions “will continue to add nearly $300 billion annually to the total health care budget.” Fortunately, the formation of Accountable Care Organizations (ACOs) offers current opportunities to transition to payment reform. Ultimately, the development of Manderschied and Kathol’s model will require that integrated financing reform be implemented over the next 3-5 years. Also essential to integration will be behavioral health and medical professionals’ “improved understanding of each other’s culture and practices,” as well as “ integrated care sites in primary, specialty medical, and specialty BH settings customized to meet the needs of the populations served.”
Sandra Bailly, M.S.W., Simmons School of Social Work, interviewed Alexander Blount, Ed.D., Director of the Center for Integrated Primary Care at the University of Massachusetts Medical School. This interview outlines what social work students should expect when learning about the practice of integrated primary care, as well as the training implications for those in that field.
Dr. Blount says that social workers and primary care providers (PCPs) face many of the same challenges, because most behavioral health issues will only ever be treated in the primary care setting. In integrated care settings, teamwork among health professionals is key. Confidentiality is slightly different in integrated settings than what a traditional therapy practice uses. Dr. Blount states:
“The unit of confidentiality in [traditional specialized] mental health is between the therapist and the patient, whereas the unit of confidentiality in primary care, and in medicine generally, is between the patient and the team.”
To fully treat a patient, PCPs and behavioral health providers must be able to share patient information. Electronic medical record (EMR) systems are a useful technology for this task. Social work students should learn how to use them and how to communicate with the PCP with them. Also, in primary care settings, therapists must be prepared to treat patients within briefer periods of interaction, and those interactions should involve teaching patients skills for dealing with their behavioral health issues.
Behavioral health and medical conditions often co-occur, so social work students need to know how to access medical information and be able to look up unfamiliar definitions. They should also have some expertise in behavioral medicine, which involves techniques such as motivational interviewing.
Prevention is a large part of the integrated care model. Integrating behavioral health and primary care helps prevent patients from having to go to specialty mental health facilities, because there are opportunities for intervention much earlier in the course of their issue or illness.
The current reimbursement system is one of the roadblocks to the integrated care model. Behavioral health interventions provided may not be billable, despite their effectiveness.
Dr. Blount recommends that schools of social work create tracks or concentrations for primary care behavioral health. Social workers who handle behavioral interventions and address the social determinants of health are essential and will be increasingly sought after.
The entire interview is available at: Integrated Primary Care: Practice and Training Implications