When behavioral health providers and primary care physicians work closely to coordinate care, the integration of mental health care with primary care doesn't have to break the bank.
Physicians who are resistant to treating patients with mental illness may soon have little choice but to embrace what some organizations believe will be the new normal—the integration of behavioral health into primary care practices.
The federal government will soon announce as much as $50 million in grants to healthcare organizations willing to make the accommodation. It's one of several signs that health systems may be getting prepared for an incoming wave of patients because of mental health parity.
The Health Resources and Services Administration says it's expecting fund at least 200 organizations with the grant. The federal agency says it received 600 applications. HRSA and the Substance Abuse and Mental Health Services Administration (SAMHSA) have been working together along with the National Council for Behavioral Health through the Center for Integrated Health Solutions to improve the health of patients who have both a chronic physical disease and mental illness.
Encouraging primary care and mental health providers to work more closely together is a growing trend. Carolinas HealthCare System announced this year it would integrate mental health into its 250 primary care clinics, and Harvard Medical School's Center for Primary Care continues to push the same approach with its Academic Innovations Collaborative partners.
Another major indicator that behavioral health providers and physicians are expected to begin working more closely to coordinate care comes from the 2014 patient-centered medical home standards released earlier this year.
"We began the integration of behavioral health with changes in 2011 but did evolve further for 2014," says Apoorva Stull, spokeswoman for the National Committee for Quality Assurance, the organization that determines the level of PCMH recognition an organization receives.
In 2014, PCMH standards for behavioral health include disclosing to patients the scope of behavioral health services available at the PCP location and establishing at least one referral relationship with a behavioral health provider. Stull says on-site integration isn't required, but is rewarded in scoring.
Beyond 'See-and-Refer'
Integration is a different approach than previous attempts at coordinating care through co-location, an improvement because the patient needing mental health help was referred to someone closer, often down the hall or at least in the same building, but co-location remains a treat-medical-issue-and-refer-mental-issue model.
Behavioral health integration means a psychologist, psychiatrist, licensed clinical social worker, or the like is available, sometimes immediately, to help a primary care physician and patient sort through the emotional response a patient may be having to a medical diagnosis.
Melissa Cormier, a licensed clinical social worker and clinical program manager for Maine Behavioral Healthcare, an integrated network of mental health providers serving patients in 11 counties across Maine, cites a recent example in one MBH's primary care clinics with a diabetic patient whose AIC levels were up significantly.
"The provider asked her what was going on, what had changed, and she said, not too much," says Cormier, adding that the patient indicated she was stressed. "The provider asked her a little bit more about her stress and she said, 'When I stress, I eat, and I probably eat the things I shouldn't.' So the provider was able to say in that moment, 'I have a colleague here, and she works with different ways to manage stress. Would you like to meet her?' "
Cormier was that colleague the provider identified, and she says she is now working on helping the patient work through different stress management techniques.
"That's a patient that wouldn't necessarily have a major depressive episode, she wouldn't have [self-] identified, wouldn't have come in to her provider, and said 'I'm depressed,'" says Cormier. Yet, "she was depressed. She had a huge amount of stress that was impacting her health."
Keeping Body and Mind Together
When patients with a diagnosis of diabetes, chronic pain, or other disease also have a mental illness, even a mild depressive episode, it is harder to for those patients to take care of themselves, which worsens their other medical conditions. The cost to health systems is enormous, and so is the cost to the public because many Medicaid patients have these comorbid conditions.
MaineHealth, the nonprofit integrated health system, which includes MBH, found its champion for integrating behavioral health into primary care in Neil Korsen, MD, medical director of MaineHealth's mental health integration program.
"There is good evidence that the referral process from primary care to specialty mental health care often breaks down," says Korsen. "The integrated clinician is a bridge that can help a patient who is ultimately going to need longer term treatment than we tend to provide in primary care."
Primary care physicians are used to seeing patients present with mild depression or anxiety in their offices, and that is one audience this integration initiative can help. Patients with diabetes, chronic pain, obesity, or who are abusing drugs and/or alcohol are the other populations that Korsen and others believe can be helped with behavioral health integration.
"We have demonstrated in almost every practice… that a half-time LCSW can be sustained with a modest level of productivity," says Korsen, who estimates nearly 30 behavioral health clinicians, mainly LCSWs, are now working across 40 MaineHealth primary care practices.
Korsen says the practices are breaking even financially, despite a recent media report about high executive pay in the wake of $2 million in cuts at a MaineHealth affiliate.
Dennis King, CEO of Maine Mental Health Partners, which has merged into Maine Behavioral Healthcare, attributes the break-even status to intricate planning and knowledge of proper use of behavior codes. Reimbursement is still a major challenge, but so is caring for a patient with a fragmented system.
"We took one person's [mental health] journey for 18 months and used post-it notes to document their care," says King. A banner marked with red, yellow, and purple post-its documented:
- 18 registrations
- 9 clinical assessments
- 17 treatment plans
- 20 providers
- 16 discharges
"The chart was 15-feet long. We calculated that we'd be able to reduce it by 2 feet. It shows how much duplication there was in our system."
A new system debuting in 2015 will both reduce the care providers and repeat interactions. There will be one registration, clinical assessment, and treatment plan, all able to be fine-tuned and changed with the coordination of a care team.
But the duplication goes beyond being a cost issue to the system. Kind says it's also harmful to patients.
"Can you imagine what it's like to have explain 10 times how your uncle raped you? It's re-traumatizing," says King. "It sounds like a small thing, but it's a big thing to a mental health patient. The human aspect of this [initiative] is pretty powerful."
Jacqueline Fellows is a contributing writer at HealthLeaders Media.