Integrating Behavioral Health With Primary Care
Integrating Behavioral Health With Primary Care
The integration of behavioral health services with primary care is designed to improve the detection, diagnosis, and treatment of mental disorders in patients seen in primary care settings. More than 50 percent of patients with a mental health diagnosis are seen by primary care providers.1 Addressing mental health and physical problems in a comprehensive, coordinated, and collaborative manner can improve the quality of care and patient health.
Innovations Exchange: What are the positive outcomes of integrated primary care?
Benjamin F. Miller, PsyD: Significant cost savings and improved health outcomes are possible when behavioral health services are integrated into medical treatment. Integrated patient-centered medical home demonstrations have been successful in increasing quality and reducing cost by decreasing hospitalizations and emergency department visits, improving patient and provider experiences of care, and developing relationships between medical practices and established systems of care. 2 , 3 , 4
What are some exemplary models of integrated primary care?
The Edward Hines, Jr. VA Hospital in suburban Chicago has six primary care teams, with a behavioral health provider on each team. Most of the behavioral health providers are located in the same office space as the primary care teams; this plan facilitates same-day open access to consultations, targeted patient evaluations, and brief treatment. If a patient prefers to wait and doesn't have an urgent need to be seen, a behavioral health provider will follow up by telephone within 24 hours.
Cherokee Health Systems in Knoxville, TN, comprises multiple primary care practices, each of which includes embedded behavioral health providers such as clinical psychologists or licensed social workers. While in the examination rooms, patients can receive behavioral and psychiatric consultations that are facilitated by the use of integrated consent forms. The behavioral health consultation is designed to help patients manage stress or depression, or make lifestyle changes that can improve their medical conditions.
What efforts are under way to examine the effectiveness of the integrated approach?
Several states are involved in research efforts to examine different models of integration:
- Advancing Care Together , sponsored by the Colorado Health Foundation, uses comparative case studies to assess the effectiveness of integrated care practices.
- A research study in Western Colorado , also funded by the Colorado Health Foundation, is examining global payment models involving five chronic diseases (hypertension, asthma, coronary heart disease, diabetes, and obesity) and three mental health conditions (anxiety, depression, and substance abuse). The goal is to show that investment in integrated care generates better health outcomes than traditional care.
- The Vermont Blueprint for Health informs providers about innovations, tools, clinical guidelines, and best practices to deliver effective, proactive care and to involve patients in managing their chronic health conditions.
- The Integrated Behavioral Health Project aims to accelerate the integration of behavioral health services into primary care settings in California by developing and disseminating evidence-based practices and tools.
- The ICARE Partnership in North Carolina seeks to increase patients' access to quality, evidence-based behavioral health care services.
What integration activities are you involved with at the national level that receive support from the Agency for Healthcare Research and Quality?
I am the principal investigator for the Academy for Integrating Behavioral Health and Primary Care , which is supported by AHRQ. The Academy is a comprehensive resource to advance the integration of primary care and behavioral health care and to foster a collaborative environment for discussion among thought leaders.
One of the Academy's projects is to facilitate workforce development by defining core competencies for the integration of behavioral health and primary care. In partnership with the Integrated Behavioral Health Project of the California Mental Health Services Authority and the Maine Health Access Foundation, the AHRQ project used an environmental scan and feedback from a national expert panel to select 10 clinical practice sites. The project team is observing the practices in action, conducting key informant interviews, and documenting the core functions of each provider.
In addition, AHRQ awarded a grant to the Department of Family Medicine at the University of Colorado a few years ago to create a research agenda to advance integrated primary care. We proposed development of a lexicon to give the research community a consistent language. The Academy recently released an updated version of the lexicon that provides a conceptual framework for all of its projects, including the development of workforce competencies and integrated quality measures.
What developments in academic training have led to advances in integrated primary care?
The disciplines of internal medicine and family medicine, in particular, have been integrating behavioral health care into medical training for several years. The Accreditation Council for Graduate Medical Education requires primary care residents to complete a behavioral health module. Almost every department of family medicine has a behavioral health scientist on staff. The focus of training, however, is shifting from simply teaching residents about behavioral health to helping residents deliver more team-based integrated interventions. Teams vary based on community needs, but in our residency program, the integrated teams include psychologists, family medicine physicians, clinical pharmacologists, nurses, social workers, and physical therapists.
When primary care and behavioral health residents complete their training, they are accustomed to thinking about collaboration within the larger health care system. Some will seek out additional training opportunities to learn what it's like to operate in a different health care environment. For example, the University of Massachusetts Medical School offers a certificate program in integrated primary care for behavioral health providers. Trainees learn the language and culture of primary care, including how to work with 15-minute interventions and brief consultations.
After they complete their training, many primary care physicians with experience in integrated care teams seek out practice settings with such teams. For example, one recent graduate turned down a job at a prestigious institution because it did not have onsite behavioral health providers.
What barriers exist to integrated primary care?
Most residency training is still conducted in professional silos, an approach that is perpetuated by the current fee-for-service reimbursement system. Having separate mental and physical health payment structures and reimbursement practices often is a barrier to better integration of care and leaves primary care to rely on referrals to mental health specialists.5 As we work toward changing our system, we want to do it in the clinical, operational, and financial realms, including a sustainable payment model that supports comprehensive integrated primary care. We need to develop a global payment structure that holds practices accountable for quality and outcomes.
What are the policy implications of integrated primary care?
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. This is a promising clinical model for addressing physical and mental health problems.
About Benjamin F. Miller, PsyD: Dr. Miller is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine, where he is responsible for integrating mental health across all three of the department's clinical, education, and research missions. Dr. Miller is also Director, Office of Integrated Healthcare Research and Policy, and Associate Director of Research and Primary Care Outreach for the University of Colorado Denver's Depression Center. He is a member of the Expert Panel for AHRQ's Health Care Innovations Exchange.
Disclosure Statement: Dr. Miller reported that his institution received payment from the Agency for Healthcare Research and Quality for his work as the principal investigator of AHRQ's Academy for Integrating Behavioral Health and Primary Care.