Integrating Behavioral and Physical Health through Primary Care
Innovative approaches are improving patient outcomes and lowering health care costs
By Lola Butcher
Trustee Talking Points
- One in five patients may be experiencing a behavioral as well as physical health problem.
- Behavioral health illnesses can make it harder for providers to treat chronic conditions.
- Behavioral health illnesses also make it harder for patients to comply with treatment protocols.
- Poor outcomes and higher costs can result from inattention to behavioral health issues.
As trustees consider how to improve the health of the communities they serve, a key fact needs to be top of mind.
“Even if you think you're not in the mental health business, you're in the mental health business,” said Ann Schumacher, president of CHI Health Immanuel in Omaha. “If you are providing care, one in five of your patients has or will experience a mental health condition.”
Hospitals and health systems that fail to address that fact suffer the consequences, as do the patients and communities they serve. Patients whose behavioral health problems — including mental and substance use disorders — are not effectively treated often become high utilizers of “physical” health services. Depression, anxiety, schizophrenia, bipolar, substance use and other behavioral health illnesses can make it harder to treat their chronic conditions — and harder for patients to comply with treatment protocols, often leading to poor outcomes and higher health care costs.
Among Medicare, Medicaid and dually eligible populations, more than 50% of adults treated for a behavioral health disorder had four or more comorbid physical conditions, according to a recent study. (See K. Thorpe et al., “Prevalence and Spending Associated with Patients Who Have a Behavioral Health Disorder and Other Conditions,” Health Affairs , https://www.healthaffairs.org/doi/10.1377/hlthaff.2016.0875.)
Certain mental health diagnoses also are associated with a reduction in life expectancy by 7 to 24 years compared to individuals without such disorders — greater than the estimated 8 to 10 years of reduced life expectancy from heavy smoking. (E. Chesney et al., “Risks of All-Cause Suicide Mortality in Mental Disorders: A Meta-Review,” World Psychiatry , https://www.ncbi.nlm.nih.gov/pubmed/24890068.)
Topics for Board Discussion
Brenda Reiss-Brennan, Ph.D., APRN, chief clinical science officer for Alluceo, an Intermountain Health company, has identified five key elements required for successful integration of mental health and physical health services through a primary care team.
Trustees might consider addressing them, using the sample questions provided below, as part of their strategic conversations. Click the icons to expand the topics for discussion.
A population-health mindset is essential, and leadership must be committed to the hard work needed to normalize mental health as a routine part of everyday care.
- Is your organization ready to make this cultural change? Who will lead the charge?
- Does your organization have an antistigma culture related to psychiatric and substance use disorders?
- Does your organization’s health plan have robust coverage for behavioral health?
Successful population health management is based on protocols for specific conditions. The complexity of each patient’s full health story must be understood so that the right level of team can be activated to meet his or her needs.
- Does your organization have standardized assessment tools that can identify a patient’s mental and physical health needs? If yes, do you have the processes and resources in place to treat newly identified patient needs?
Data about patient outcomes, costs, clinical care and operations must be synthesized, analyzed and communicated to the primary care teams in your organization.
- Does your organization have the data analytics capability needed to evaluate what works, what doesn’t and how to keep fine-tuning processes for improved performance?
Understanding the right leadership and staffing mix for operational efficiency requires savvy management and the right targeted amount of investment.
- Do your teams have quantifiable data about the complexity of your patient population? Can it stratify patients so they receive the right level of care at the right time? And is someone accountable for analyzing the business case for integration?
A primary care clinic cannot meet every identified patient need. Some patients and families will need referrals to other providers for longer-term or more intensive interventions; some will need ongoing support to succeed after short-term treatment ends.
- What other local providers and resources can (has) your organization partner(ed) with to help patients continue to thrive?
CHI Health Immanuel and others have found that integration of behavioral health services with physical care — particularly primary care and behavioral health clinicians working together with patients and families to address their whole health — is essential to providing high-quality care. The payoff: Patients feel better and overall costs are reduced.
Executives at three leading organizations have shared the lessons learned from their success at integrating behavioral and primary care. They use different approaches, but each emphasized “integration” — challenging, but essential — as the key.
“I would caution folks across the nation: Don't just replicate a mental health clinic inside a primary care practice,” said Scott Oxley, senior vice president for Northern Light Health in northern Maine. “Make sure it's truly a collaborative, patient-centered model where behavioral health professionals are part of a team managing the overall wellness of all of your patients.”
Why integration matters
Intermountain Healthcare, based in Utah, was a pioneer when it started integrating mental health care into primary care clinics in 1999. Its goal was not just to diagnose and treat mental illness, but to help patients achieve “mental wellness” as a crucial part of their overall health, said Brenda Reiss-Brennan, Ph.D., APRN, Intermountain’s mental health integration director.
“That really resonated with our primary care docs because that’s what they needed help with,” she said. “Patients come into their medical visit with many social and mental health-related issues — fatigue, not eating or sleeping, divorce, pain, violence — in addition to their chronic medical conditions.”
The benefits of integrating mental and physical health care, for patients and providers alike, have been surmised for years. But Intermountain provided the proof in 2016, when the Journal of the American Medical Association published the results of a 10-year study of integrated care delivered in a team-based primary care setting. The comparison of more than 110,000 adult patients who received care in 113 practices — about a quarter of which delivered integrated care — showed that:
• Because so many more patients were screened for depression in the team-based practices, 46% of patients were diagnosed with active depression, nearly double the rate diagnosed in traditional practices.
• Nearly 25% of patients in team-based practices were actively addressing their diabetes, compared to less than 20% in traditional practices.
• The rate of emergency department visits was 23% lower for patients in team-based practices than in traditional practices. The rate of hospital admissions was nearly 11% lower, and the number of primary care physician encounters was 7% lower.
Innovative points of access
Allan Currie, M.D., an internist at Northern Light, has seen the opportunity for years. Patients’ chronic conditions — diabetes, congestive heart failure, chronic obstructive pulmonary disease — are too often uncontrolled, despite good medical care.
“Many, many times the reason for that is not medical, it's psychological,” he said. “They're depressed, or they're stressed, or they have family issues, or financial issues. Until you get the psychological issues better, you can't get the medical issues better.”
Dr. Currie is a trustee at Northern Light Acadia Hospital, the system’s tertiary psychiatric hospital and community mental health agency in Bangor, Maine. For the past eight years, Acadia has been providing mental health services in primary care clinics.
“That is a big advantage because patients are much more receptive to that,” he said. “They can come right back to my office and see somebody right here down the hallway.”
Starting with a single psychiatric mental health nurse practitioner embedded in a primary care clinic, the integrated approach at Northern Light has grown to include 14 nurse practitioners and 13 licensed clinical social workers (LCSW) supporting 40 primary care practices across the state. In most of those practices, the mental health professionals are physically integrated with other members of the care team, but telepsychiatry serves more than 30% of the clinics.
“In those cases, we have both a nurse practitioner and an LCSW sitting somewhere else — valued team members who are part of that practice — who are supporting the patients and the care teams through tele-video,” said Oxley, who also serves as president of Acadia Hospital.
Telepsychiatry allows Northern Light to provide services in a large number of rural communities in which mental health professionals are often not available. Oxley points to one nurse practitioner — a Northern Light employee — who lives in Indiana and has been supporting five rural Maine primary care clinics for many years.
Resources on Behavioral Health
The American Hospital Association has a long-standing commitment to support member efforts to deliver high-quality, accessible behavioral health services. Consistent with that commitment, a web page has been designed to provide easy access to information and tools that will assist them in navigating the changing behavioral health care system and understanding national, state and local activities affecting behavioral health.
To access the web page, visit https://www.aha.org/behavioralhealth.
As boards seek to improve access to care and improve the “whole health” of the community, technology can play an important role in addressing behavioral health needs. To assist boards and other health leaders, the American Hospital Association and the National Quality Forum have released “Redesigning Care: A How-to Guide for Hospitals and Health Systems Seeking to Implement, Strengthen and Sustain Telebehavioral Health.” The guide is designed to help hospitals and health systems deliver innovative, high-quality telebehavioral health services.
To access the guide, visit https://www.aha.org/center/emerging-issues/market-insights/telehealth/telebehavioral-health.
“If it was not for that model, that would be a part of the state of Maine that just wouldn't have access to these very important services,” he said.
In a Northern Light clinic where a mental health professional is present, a primary care provider can make a “warm handoff” (a transfer of care between members of the care team that incorporates the patient and family) for an assessment or treatment of a behavioral health issue. Patients can be treated in the primary care clinic for a few follow-up appointments and medication management, if needed. If they need more significant intervention, they are referred to a specialist at a Northern Light psychiatric clinic or a provider available through telepsychiatry.
The integrated model reduces the stigma that some patients had still associated with mental health services, said Michelle Hood, president and CEO of Northern Light Health and an American Hospital Association board member. Spreading that model of care holds enormous potential for improving the value of health care services.
“Trustees are in a unique position to be able to advocate on behalf of their community: The more we can do to remove stigma by having behavioral health needs addressed at a primary care site, the healthier our communities will be,” she said.
Adding value to primary care
Schumacher has seen many benefits since CHI Health Immanuel started integrating behavioral health services in primary care clinics in 2015: Patients get mental health evaluations, diagnoses and treatment plans more quickly; primary care physicians increase the number of patients they can see; and emergency department visits, primary care utilization and total cost of care are all reduced.
Best of all, patients feel better as their whole health improves. “Integrating behavioral and primary care has helped us improve our patient outcomes because we're identifying and treating the mental health condition sooner,” said Schumacher, who is also former chair of the AHA’s Council for Psychiatric and Substance Abuse Services.
Integration of behavioral health services with physical care is essential to providing high-quality care. Among the many benefits are the following:
- Patients get mental health evaluations, diagnoses and treatment plans more quickly.
- Primary care physicians are able to increase the number of patients they can see.
- Emergency department visits, primary care utilization and total cost of care are all reduced.
- Best of all, patients feel better as their whole health improves. And professional life is often improved for primary care providers.
CHI Health Immanuel has integrated care in nine mental health/primary care clinics. On average, patients referred to an embedded therapist can be seen within two days of the initial referral — compared with a months-long wait to access services in the community.
For most patients — 84%, in fact — a single consultation is sufficient for a treatment plan to be established, with brief therapy and medication management, if needed, handled by the therapist on site. For patients with more complex needs, the therapist coordinates referrals to the appropriate specialist — a psychologist, psychiatrist, chemical dependency counselor or other clinician, all of whom are part of the same service line as the embedded therapist.
“We've seen significant improvement in collaboration between our primary care and our service line because the embedded therapists can be the go-between and are the experts in both worlds,” Schumacher said.
CHI Health Immanuel has seen a 4% decrease in emergency department visits by patients referred for behavioral care, along with fewer primary care visits and lower total cost of care.
A bonus benefit: Professional life is often improved for primary care providers.
In a collaborative care or integrated care model, when a primary care physician thinks a patient may be struggling with a mental or substance use disorder, the provider can quickly refer him or her to a behavioral health therapist down the hall for evaluation and treatment. One goal of integrated care is to use the system’s electronic medical record to integrate both behavioral health and primary care needs and treatment plans, so all clinicians can stay apprised of the patient’s diagnoses and services. Moreover, a therapist is nearby when a provider needs advice.
“Our primary care providers are on the front lines of caring for people with mental illness, so we are able to provide education and consultation to them in real time,” Schumacher said. “There's a lot more support for that primary care practitioner to serve his or her patients.”