Integrated Behavioral Health Reduces Depression and Anxiety in Primary Care Patients, Improving Quality of Life and Reducing Costs

Service Delivery Innovation Profile

Integrated Behavioral Health Reduces Depression and Anxiety in Primary Care Patients, Improving Quality of Life and Reducing Costs

Snapshot

Summary

People's Community Clinic integrates assessment and treatment of behavioral health issues into primary care services for its largely low-income population. Based on the Improving Mood Promoting Access to Collaborative Treatment (more commonly referred to as IMPACT) model, the program uses primary care physicians to ask basic questions to identify suspected cases of depression and anxiety. Physicians then refer these patients to an onsite social worker for a more formal assessment. Those who screen positive for depression or anxiety receive a referral to an onsite behavioral health specialist who provides cognitive behavioral therapy, works with the patient's physician to identify appropriate medications, and monitors the patient on an ongoing basis. A consulting psychiatrist assists with complex cases and works with the behavioral health specialist and physician as needed. The program enhanced access to mental health care services, improved quality of life, and reduced the incidence of depression and anxiety, utilization of primary care and emergency department services, and overall health care costs. Spanish-speaking patients appear to have benefited disproportionately from the program in certain areas.

Evidence Rating

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of self-reported quality of life scores and depression and anxiety scale scores, as well as data on utilization of ED and primary care services and overall health care costs from a region-wide database on health care delivery by safety net providers.

Developing Organizations

People's Community Clinic; UCLA Neuropsychiatric Institute; University of Washington Department of Psychiatry & Behavioral Sciences

Austin, TX

Use By Other Organizations

The seven sites that received 3-year implementation grants from the Hogg Foundation for Mental Health included People's Community Clinic, Brownsville Community Health Center (Brownsville, TX), Nuestra Clinica del Valle (San Juan, TX), Parkland Health and Hospital System (Dallas, TX), Project Vida Health Center (El Paso, TX), Su Clinica Familiar (Harlingen, TX), and Texas Children's Pediatric Associates (Houston, TX). Additional information about the demonstration grant program can be found on the Hogg Foundation's Web site at: http://mhdaily.org/tag/grants/.

 

 

Date First Implemented

2006

Problem Addressed

Mental health conditions are common and often lead to significant negative consequences. Although many patients with such conditions receive care in the primary care setting, most primary care physicians (PCPs) remain ill-equipped to treat these conditions on their own. Integrating mental health assessment and treatment into primary care can yield clinical and cost benefits, but most clinics have not taken this step.

  • A common, costly disorder: The U.S. Preventive Services Task Force (USPSTF) estimates that between 5 and 9 percent of Americans have a major depressive disorder, with the total direct and indirect costs of such disorders running as high as $43 billion annually. Approximately 5 to 10 percent of older adults seen in primary care practices suffer from major depression or dysthymia (a less severe form of chronic depression).
  • Significant negative consequences: Conditions such as depression and anxiety can cause functional impairment and have a major negative effect on quality of life. For example, adults with depression use more medical services, experience more physical symptoms, adhere less well to medication regimens, and engage in poorer self-management behaviors than do adults without depression; depressed adults also face an increased risk of death both from suicide and medical illnesses.,
  • Failure of primary care to diagnose, treat mental health conditions: PCPs provide roughly half of all mental health care, and 92 percent of older adults receive mental health care from their PCP. However, PCPs often fail to diagnose or successfully treat mental health conditions. For example, one study of 500 primary care patients found that 29 percent had mental health conditions, but providers identified only one third of these conditions over a 5-year period. Despite links between physical and mental health, most primary care clinics do not have comprehensive, integrated programs to assess mental health conditions, nor do they have onsite mental health providers to provide needed treatment and monitoring.,

Description of the Innovative Activity

A primary care clinic offers integrated behavioral health care based on the IMPACT model. PCPs ask patients basic questions to identify suspected cases of depression and anxiety, and then refer these patients to an onsite social worker who uses screening tools to perform a more formal assessment. Those who screen positive receive a referral to an onsite behavioral health specialist who provides cognitive behavioral therapy, works with the patient's PCP to identify appropriate medications, and monitors the patient on an ongoing basis. A consulting psychiatrist assists with complex cases and works with the specialist and PCP as necessary. Patients typically remain in the program for 6 to 9 months. Key elements of the program include the following:

  • Initial identification by PCPs: A PCP asks basic questions to identify patients who may have depression and/or anxiety, and then refers these individuals to an onsite social worker for more formal assessment. Physicians incorporate basic screening questions into the general physical examination; questions address common mental health-related issues such as sleep patterns, stress level, and changes in mood. To ensure the identification of suspected depression in diabetes patients (who are more likely than the general population to suffer from depression), physicians ask those with diabetes at each visit whether they have had little interest or pleasure in doing things, and if they have felt down, depressed, or hopeless within the last 2 weeks.
  • Mental health assessment by social worker: The social worker uses the Patient Health Questionnaire-9 (PHQ-9) to screen for depression and the Overall Anxiety Severity and Impairment Scale (OASIS) to screen for anxiety. If the patient does not score at a level that signifies clinical depression or anxiety but still exhibits some level of symptoms, the social worker may provide short-term counseling.
  • Referral to behavioral health specialist: Those who screen positive for depression and/or anxiety receive a referral to an onsite behavioral health specialist (also known as a care manager), who performs a more rigorous clinical assessment, including re-administering the PHQ-9 and the OASIS.
  • Ongoing, collaborative mental health care: The behavioral health specialist communicates the outcome of the assessment to the PCP, and the two jointly develop a formal treatment plan that outlines medical therapy, cognitive behavioral therapy, and/or the need for consultation with a psychiatrist. Throughout treatment, the PCP remains the central care provider, with the behavioral health specialist and/or consulting psychiatrist collaborating on the following aspects of mental health care:
    • Medication therapy: The behavioral health specialist and PCP discuss the outcome of the patient assessment, with the PCP writing prescriptions for any needed medications, taking the behavioral health specialist's feedback and psychiatrist's recommendations into consideration.
    • Cognitive behavioral therapy and followup: The behavioral health specialist provides cognitive behavioral therapy if indicated (with a focus on problem-solving), educates patients about their mental health condition, and helps them address barriers to treatment. The specialist telephones or sees the patient on a weekly or biweekly basis to provide extra counseling and encouragement, and to ensure adherence to the prescribed medication regimen. The behavioral health specialist meets with the average patient roughly four times in person and seven times via telephone followup.
    • Consultations on difficult cases: A consulting psychiatrist from the local community mental health center works at the clinic 4 hours a week. He consults with the behavioral health specialist and the physician on difficult cases, occasionally performs psychiatric evaluations of patients who are diagnostically complex and/or remain unresponsive to therapy, and suggests alternative therapeutic options as appropriate.
  • Ongoing assessment of patient response: The behavioral health specialist tracks the patient's symptoms over time to determine response to treatment by readministering the PHQ-9 and OASIS during every phone call or inperson meeting. Patients who improve and exhibit several months of stability can be discharged from the program. For those who do not respond to treatment, the behavioral health specialist meets with the physician to suggest a dosage increase or an alternative therapy. The typical patient remains in the program for 6 to 9 months, although some require support for a longer period.
  • Registry to assist in patient monitoring: The behavioral health specialist enters each patient interaction and the results of each patient assessment into a registry of all patients enrolled in the program. The registry, adapted and provided by the IMPACT program, enables the collaborative care team to graphically view a patient's assessment scores and symptoms over time. It also flags patients who have not been contacted within a designated amount of time, and those who have not improved their original assessment scores by at least 50 percent over the first 10 weeks of treatment.

Context of the Innovation

People's Community Clinic, a freestanding, private, nonprofit clinic located in Austin, TX, began in 1970 as a volunteer clinic located in the basement of a local church. The clinic, which now includes six physicians and eight midlevel providers (nurse practitioners and physician assistants), treats approximately 12,000 largely low-income patients annually. Hispanic immigrants comprise a growing portion of the patient population. The clinic offers a broad continuum of primary care services, including prenatal services, pediatric and adolescent care, general adult medicine, and geriatric care. The practice serves uninsured (self-pay) patients and those covered by Medicare, Medicaid, or the State Children's Health Insurance Program; it does not serve those with private insurance. For many years, clinicians had identified mental health care as a significant unmet need, with approximately one-fourth of patients experiencing some mental health difficulties. Originally, providers would refer these patients to community resources; in more recent years, the practice attempted various internal strategies, such as sharing a psychiatrist with a nearby mental health practice and using an onsite licensed social worker to manage mental health issues. Ultimately, the clinic's providers felt that they could better serve patients by developing a systemic solution that incorporated comprehensive mental health resources into the practice. The clinic applied for a 3-year grant from the Hogg Foundation for Mental Health, which wanted to encourage the implementation of the IMPACT model in Texas across a variety of age groups and diagnoses. IMPACT, developed by the UCLA Neuropsychiatric Institute's Center for Health Services Research and the University of Washington Department of Psychiatry and Behavioral Sciences, had been previously shown in a randomized controlled trial to provide significant benefits for an older, depressed population.

Results

The program enhanced access to mental health care services, improved quality of life, and reduced depression and anxiety, utilization of primary care and emergency department (ED) services, and overall health care costs. Spanish-speaking patients appear to have benefited disproportionately from the program in certain areas.

  • Enhanced access to mental health care: The clinic found that 47 percent of enrolled patients had no previous mental health treatment. This suggests that the clinic's integrated behavioral health program is offering a much needed service to people with serious mental health concerns whose mental health needs have not, until now, been appropriately addressed.
  • Improved mental health care quality: Not only have patients received care that they otherwise might not have, but the quality of care is likely higher. Patients who reported receiving prior mental health treatment often did not receive it from a mental health specialist. For those patients who reported that they have previously received mental health treatment, the clinic's integrated behavioral health program has provided them with either a different diagnosis (9 percent of patients) or a more detailed/specific diagnosis (48 percent of patients) than they previously received.
  • Improved quality of life: Program enrollees reported having better overall health, more energy, and less pain since beginning the program; they also report being more likely to socialize and being able to accomplish more since enrollment.
  • Less depression and anxiety: The program reduced patients' depression and anxiety, as outlined below:
    • Lower depression scores: Depression scores on the PHQ-9 fell from an average of 16.43 at baseline (classified as moderately severe depression) to 8.1 (classified as mild depression) on the most recent assessment. In addition, 61 percent of patients experienced a 50 percent or greater decline in depression scores after 3 months in the program, a significantly higher proportion than the 29 percent of usual care patients who experience such a decline (as reported in the literature) and well above the 40 percent goal set by the Institute for Healthcare Improvement. An even higher percentage—78 percent—of Spanish-speaking patients experienced a 50 percent or greater reduction in depression scores, suggesting that the program had a major benefit for this particularly underserved population.
    • Less anxiety: Scores on the OASIS instrument fell by 50 percent (or an average of 5.73 points) in program participants between baseline and their latest evaluation.
  • Fewer primary care and ED visits: Primary care and ED visits were examined for patients for the 12-month period before they entered the integrated behavioral health program. Patients' primary care provider and ED visits were escalating during this time and deviating substantially from that of a typical uninsured patient in central Texas. However, with program participation, this trajectory was reversed. Primary care and ED visits significantly declined in the intervention period and at 27 months followup were below levels exhibited before program participation and below use levels of a typical uninsured central Texas patient. The drop in primary care utilization has been especially pronounced among Spanish-speaking enrollees. Before program participation, these enrollees used twice as much primary care as did the clinic's English-speaking patients; after 3 years of program operation, that discrepancy had been eliminated.
  • Much lower overall health care costs: The average health care costs per enrollee (for primary care, emergency care, counseling, and care manager visits) fell significantly, from $196 per quarter at implementation to $87 per quarter after 27 months of program operation. The program did require an initial investment that prompted 39 percent higher year-one costs than costs in the year before the program began. However, in the second year of operation, integrated behavioral health patient costs were 17 percent lower than in the year before the program was adopted (usual care). These cost savings were even more substantial in the first quarter of the third year of operation (56 percent lower).

Evidence Rating

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of self-reported quality of life scores and depression and anxiety scale scores, as well as data on utilization of ED and primary care services and overall health care costs from a region-wide database on health care delivery by safety net providers.

Planning and Development Process

Key steps in the planning and development process included the following:

  • Identifying program champion: The clinic identified a physician champion who believed in the model and participated in its adoption and implementation.
  • Formal training and job shadowing: Clinic staff, including PCPs, received formal training from IMPACT program developers. The behavioral health specialist initially “shadowed” several providers to increase her understanding of their workflow and to help them become more comfortable with her and the types of interventions she could offer.
  • Monthly telephone consultations: During the first 3 years of the program, the team held monthly telephone calls with a consulting psychiatrist from the University of Washington (where the IMPACT program originated). These calls helped to ensure smooth and appropriate implementation of the integrated behavioral health care model.
  • Expanding program: The program has expanded beyond general adults to serve adults with diabetes and older adolescents. Program leaders plan to expand the program to pediatric patients with mental health issues, many of whom have attention deficit hyperactivity disorder combined with other mental health problems.

Resources Used and Skills Needed

  • Staffing: The program includes three full-time employees, all of whom are licensed clinical social workers. One serves as the behavioral health specialist for the general adult population. The other two spend half their time assessing and triaging patients and the other half serving in the behavioral health specialist role (one for older adolescents and one for adults with diabetes). The program also has a half-time administrative assistant. The full-time (adult) behavioral health specialist serves between 60 and 70 patients at a time, although program developers believe the ideal caseload to be between 50 and 60 patients.
  • Costs: The program costs approximately $300,000 annually, including labor and medication costs (which are covered by the clinic until qualifying patients enroll in a pharmaceutical assistance program).

Funding Sources

The Hogg Foundation for Mental Health provided an initial 3-year grant, which was supplemented by a multiyear grant from the St. David's Foundation to fund various aspects of the program. People's Community Clinic has also secured reimbursement for adult inperson mental health visits from Central Health, the health care district for Travis County.

Getting Started with This Innovation

  • Obtain technical assistance: Clinic representatives note that technical assistance from IMPACT developers proved critical to ensuring smooth adoption of the model.
  • Identify physician champion: A PCP who strongly believes in the model should serve as program champion, participating in all training and helping to secure buy-in from other staff by addressing concerns expressed by other clinic providers and demonstrating support for the behavioral health specialist (who may not receive support from other staff because this individual is not a psychiatrist or psychologist).
  • Involve all staff: Share research regarding the benefits of the program with all staff, and ensure that everyone understands his or her particular role. In addition, emphasize with providers that referring patients to the program will make their own jobs easier while improving service. When new providers join the clinic, have the behavioral health specialist introduce him- or herself and discuss the program.
  • Embrace nonhierarchical, multidisciplinary approach: The model works best when all involved providers, including PCPs, psychiatrists, and social workers, believe they contribute equally to the care of the patient.
  • Carefully consider skills of behavioral health specialist: Behavioral health specialists must not only be dedicated to helping patients resolve their mental health issues, but also must understand the myriad of psychosocial factors that may contribute to these issues. Although other types of providers may serve as behavioral health specialists, social workers fill the role especially well because they have experience with the wide range of mental health and social service issues faced by patients.

Sustaining This Innovation

  • Ensure continuing funding: Many programs end when initial grant funding runs out. People's Community Clinic has been able to sustain the program by securing ongoing funding from one private foundation and limited reimbursement (for inperson adult visits only) from the county health care district.
  • Emphasize value for minority populations: By integrating behavioral health care into a primary care practice, the practice has improved access to mental health care for minority populations, who often do not seek mental health care, in part due to the stigma associated with such care in their communities. This argument can be used to underscore the value of the program to potential funders.

Use By Other Organizations

The seven sites that received 3-year implementation grants from the Hogg Foundation for Mental Health included People's Community Clinic, Brownsville Community Health Center (Brownsville, TX), Nuestra Clinica del Valle (San Juan, TX), Parkland Health and Hospital System (Dallas, TX), Project Vida Health Center (El Paso, TX), Su Clinica Familiar (Harlingen, TX), and Texas Children's Pediatric Associates (Houston, TX). Additional information about the demonstration grant program can be found on the Hogg Foundation's Web site at: http://mhdaily.org/tag/grants/.

 

 


Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

Robin Rosell, LCSW, LMFT Director of Social Services
People's Community Clinic
Austin, TX
E-mail: RobinR@austinpcc.org

Toni Terling Watt, PhD
Associate Professor, Sociology Department
Texas State University
San Marcos, TX
E-mail: tw15@txstate.edu



Innovator Disclosures

Dr. Terling reported having no financial interests or business/professional affiliations relevant to the work described in the profile other than the funders listed in the Funding Sources section.

Ms. Rosell has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Watt T. A Process and Outcome Evaluation of Two Integrated Healthcare Models. Reports for years 1, 2 and 3 are available at: http://docplayer.net/9632795-A-process-and-outcome-evaluation-of-two-integrated-behavioral-health-care-models-people-s-community-clinic-and-lone-star-circle-of-care.html.


IMPACT Web site: http://aims.uw.edu/impact-improving-mood-promoting-access-collaborative-treatment/. Evidence supporting the IMPACT model is available at: http://aims.uw.edu/collaborative-care/evidence-base.

Unutzer J, Katon W, Callahan CM, et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836-45. [PubMed] Available at: http://jama.jamanetwork.com/article.aspx?articleid=195599.

Katon W, Schoenbaum M, Fan MF, et al. Cost-effectiveness of improving primary care treatment of late-life depression. Arch Gen Psychiatry. 2005;62(12):1313-20. [PubMed] Available at: http://archpsyc.jamanetwork.com/article.aspx?articleid=209123.

Unutzer J, Katon W, Fan MF, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care. 2008;14:95-100. [PubMed] Available at: http://www.ajmc.com/media/pdf/AJMC_08feb_Unutzer_95to100.pdf.

Footnotes

  1. Strosahl K, Robinson P. Integrating primary care and behavioral health services: a compass and a horizon. PowerPoint presentation, Virginia's State Rural Health Plan; 2009. Available at: https://www.apa.org/practice/programs/rural/integrating-primary-behavioral.pdf.

  2. Agency for Healthcare Research and Quality. U.S. Preventive Services Task Force now finds sufficient evidence to recommend screening adults for depression. Rockville, MD: Agency for Healthcare Research and Quality; 2002.

  3. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136(10):765-76. [PubMed]

  4. Unutzer J, Katon W, Callahan CM. et al. Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. JAMA. 2002;288(22):2836-45. [PubMed] Available at: http://jama.jamanetwork.com/article.aspx?articleid=195599.

  5. Katon W, Schoenbaum M, Fan MF, et al. Cost-effectiveness of improving primary care treatment of late-life depression. Arch Gen Psychiatry. 2005;62(12):1313-20. [PubMed] Available at: http://archpsyc.jamanetwork.com/article.aspx?articleid=209123.

  6. Jackson J, Passamonti M, Kroenke K. Outcome and impact of mental disorders in primary care at 5 years. Psychosom Med. 2007;69:270-6. [PubMed] Available at: http://www.psychosomaticmedicine.org/cgi/content/abstract/69/3/270

  7. Watt T. A Process and Outcome Evaluation of Two Integrated Behavioral Health Care Models: People's Community Clinic and Lone Star Circle of Care. Year-Three Final Report. Texas State University. Fall 2009.

Funding Sources

Hogg Foundation
St. David's Foundation

Developers

People's Community Clinic, UCLA Neuropsychiatric Institute, University of Washington Department of Psychiatry & Behavioral Sciences

Austin, TX

Original Publication: 11/24/10

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 10/23/13

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 09/27/12

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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