Integrated Behavioral Health Care
Integration of behavioral health and primary care in highly diverse fast growing ambulatory care settings
Co-morbid medical and behavioral health issues are a significant burden, driving poor outcomes and high costs in US health care system per published and unpublished organization level and payer level data. As a recognized Patient-Centered Medical Home (PCMH), integration of behavioral health and ambulatory care (both in our primary care and high risk specialty clinics) is one of our current critical area of focus for the success and sustainability of our organization.
Based on the recent needs assessment (medical, behavioral and social needs) of our patient population and analysis of our 2015 and 2016 data from electronic health records for percentage of our patients with current behavioral health diagnosis, we have identified increased demand and necessity to optimize the level of behavioral health and primary care integration in all our locations (We currently have a co-located model in few of our clinic locations facilitating warm hand-off to support our patients behavioral health and medical needs).
In our integration enhancement analysis, we have identified several barriers:
- Financial barriers:
- Substantial need for the initial investment to redesign the care team, hire and or retrain staff. These initial investments would not be reimbursed by the payers. One option for us is to be prepared to operate at a loss in this initial stage of integration enhancement given our commitment to providing high-quality care to our patients and community.
- While we understand very well that integration in our PCMH will eventually lead to cost savings, one additional problem we foresee is that the savings most likely would accrue to different parts of the health care system (payer or hospital) than where the expenditure is needed (primary care).
- Clinical and operational barriers:
- Given the large size of our organization with several satellite clinics located independently or in our Housing service areas, standardizing and operationalizing the core components of integration into clinical workflows would be an interesting challenge with several issues including but not limited to staff engagement, divided middle management, merging two distinctly different cultures (behavioral health and primary care) and modifying EMR.
One of the strong points we have currently in support of this project is all of us in the executive team are committed to this practice transformation, which means we will present from our leadership team a shared vision of enhanced integrated care to all staff.
We have incorporated behavioral health into our primary care sites over this past year. It has been recieved quite well from both sides. The psychologist I have embedded in my office is available for integrated visits, meaning I can often walk down the hall and get her for a 15 min quick visit for someone that is really struggling- freeing me up to move on to the next patient. The psychologist is able to triage and start a treatement plan to complement what I do. Work flows are easy to develop.
financially it’s a win because insurance tends to cover this service in our area. We are also exploring how chronic disease can benefit from behavioral health involvement. Things like pain and addiction are easy to see the connection, but things like poorly controlled diabetes are also benefitting. We’ve had behavioral health in our system for a long time, but access was poor and they seemed very silod and distant. Having them in my office is great. They participate in our office meetings like they are one of the group. I would hate to think of practicing in an office now without integrated behavioral health.
This is certainly the direction I believe more and more primary care practices will continue to move towards as the ability to identify high-risk co morbid medical and behavioral health issues will drive costs down so they can be addressed in this setting and not a more costly one downstream. Because PCPs have not been previously tasked with delivering this care, I can see how there are real financial burdens to increasing training, staff, practice space, and risk in caring for and treating these patients. There are also a number of digital and third party solutions that working to provide support both to primary care practices as well as ER discharges to support patients with co-morbidity using a number of different supports (diagnostic tools, telemedicine, case management, psychologist/psychiatrist referral networks). These solutions can take the risk/burden off of the provider while helping them save costs in the long term.
Important topic. What kind of patient population you have in PCMH? That defines what kind of integration would be optimal. While you can train staff to give non-specific psychosocial support, which in many case would be enough it is important to identify disorders that can be treated e.g by specific brief psychotherapies. Scalable specific web-based psychiatric treatments, or group therapies work if you have the right patient population. Large use of web-based solutions is good for many topics as Amanda points out.