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Integrating Mental Health in the Primary Care Setting: The Case in the U.S. and Abroad

Added on 14 Feb 2014

Authors: By Sophie Beauvais; Reviewed by Giuseppe Raviola, MD, MPH, and Rebecca Weintraub, MD

One in four adults −approximately 61.5 million of Americans− experiences mental illness in a given year. One in 17 − about 13.6 million − live with a serious mental illness such as schizophrenia, major depression or bipolar disorder. (The National Alliance on Mental Illness, NAMI. 2013) Globally, people with mental disorders experience disproportionately higher rates of disability and mortality. (World Health Organization. 2013) Between 76% and 85% of people with severe mental disorders receive no treatment for their disorder in low-income and middle-income countries, the corresponding range for high-income countries is also high: between 35% and 50%. (WHO. 2013)

In the U.S., treatment of mental illnesses has gone from an inpatient model to an outpatient and community-based model. Since November 2013, health insurance companies are required to treat mental illness and addiction the same as physical illness as part of the Affordable Care Act (ACA). In poor and developing countries, the WHO states, mental health is often neglected and the quality of care is poor with very few mental health professionals. There, the WHO argues, redirecting funding for mental health towards community-based services would allow access to better and more cost-effective interventions for more people. A more recent model, however, calls for the integration of mental health in the primary care setting, and the U.S. Agency for Healthcare Research and Quality (AHRQ) provides reports that review existing models of integration, highlighting pros and cons, and discuss the role of various health professionals as well as the potential for Health IT. From November 18-22, 2013, experts from NAMI, The Center for Health Care Strategies, Boston Children's Hospital, Harvard Medical School, and Partners In Health, discussed this topic with GHDonline members in a virtual Expert Panel organized as part of the US Communities Initiative.

Key Points

Integrating Mental Health in the Primary Care Setting: Challenges and Promises

  • While this approach seems to achieve positive outcomes overall, AHRQ reports that the literature is less clear on benefits and identifies numerous challenges, “without evidence for a clearly superior model, there is legitimate reason to worry about premature orthodoxy.” (AHRQ. October 2008. Report No.: 09-E003.)
  • Collaborative care interventions improved outcomes for depression and quality of life in primary care patients with multiple different medical conditions. (AHRQ. August 2012. Report No.: 12-EHC106-EF.)
  • The AHRQ evidence report finds that primary care physicians (PCPs) who used evidence-based practice for depression care alone had outcomes as good as mental health practitioners, but that the primary care setting is most likely to accommodate treating mental health conditions when the treatment can be adapted to the primary care setting. This review finds that the bulk of the evidence in the integration of primary care into the mental health setting comes from the US Department of Veterans Affairs.
  • Providing mental health in a primary care setting has particular challenges, such as overcoming the stigma associated with mental illness, the chronicity of the diseases that many patients face, and missed or inaccurate diagnosis. PCPs need to receive training and sometimes be supervised to support and manage the provision of mental health services.
  • For people with serious mental illness, the integration may need to occur on the mental health side. Finding sustainable models for this is challenging. The Affordable Care Organization (ACO) model which aligns payer incentives with outcomes is an opportunity to advance this.
  • A more diversified workforce is needed in an integrated setting because of the unique demands that it creates. Additionally, the vast array of mental health professionals: nurses, social workers, psychologists and psychiatrists, peer supporters, etc. needs to be mobilized in integrated systems, and collaboration among all health care professionals is critical.
  • There are still many challenges with the delivery of mental health services in the U.S. as reported by a GHDonline member in Texas who went in and out of inpatient and outpatient services multiple times and testified that these “did not help that much” until going to a specialized treatment program.
  • Mental health should be better integrated into the basic curriculum of general nursing and medical students, and into the continued professional training of nurses and medical doctors.
  • In 2011, the World Health Organization developed the Mental Health Gap Action Programme (mhGAP), a guide for non-specialist providers to support the need for “skill-package based planning.”
  • In many low-income countries such as Rwanda, for example, there is a strong commitment to improve mental health services within the primary care setting. But there are significant gaps between the treatment needs and the human resources available. Structural barriers to care (e.g transportation, medication and lab support) are also a problem.

Examples of Approaches in Integrated Care in the U.S. and Abroad

  • In the U.S., there are successful co-location or preferred referral models. For example, a health center might either employ or contract with another organization to provide a mental health expert - a licensed social worker typically - to work with the health center. That model is evolving into a best practice that includes the following traits: blended care team; shared support staff and physical space; well orchestrated clinical flow; one clinical record, unified treatment plan; immediate communication; shared patient population; reimbursement mechanisms support the model; expanded, behavior-focused Patient-Centered Medical Homes (PCMH); blended and purposefully blurred professional roles; targeting high-risk, high-need populations; integration defines corporate identity and mission; partnership with payers; and being in sync with the goals of healthcare reform and the Triple Aim (Care, Health, Cost).
  • Dozens of states in the U.S. are working to design more integrated models of care for their entire population, regardless of payer, via the State Innovation Model initiative.
  • Cherokee Health Systems in Knoxville, Tennessee provides a behaviorally-enhanced patient centered medical home and employs highly-skilled, well-trained behaviorists (also known as Behavioral Health Consultants, BHCs) on primary care teams. The BHCs and the primary care physicians (PCPs) are supported by a consulting psychiatrist to help with the general care of the population-based caseload, as well as to facilitate knowledge transfer for a much more informed and responsive care team. BHCs are trained by the organization as outside graduate and doctoral programs are lacking.
  • The Crimson Care Collaborative (CCC) at the Massachusetts General Hospital, Chelsea Healthcare Center in Boston, Massachusetts targets two populations: 1) recently incarcerated individuals and 2) patients who are high-utilizers of urgent care services. CCC has implemented a version of IMPACT, an evidence-based program for delivering behavioral health services.
  • Also in Massachusetts, a new model gives primary care providers the option to take on any one of three levels of responsibility for behavioral health integration: 1) taking on new care coordination responsibility; 2) providing a limited array of brief behavioral health interventions; and 3) providing onsite psychiatric support. Participating practices receive a bundled payment based on which level of integration they support. The initiative rolled out early 2013, and many are watching closely to learn from this experience.
  • In Pennsylvania, two regional pilots (SMI Innovations Project) were sponsored to create new incentives for payers to support integrated care. Specifically, managed care plans (both those managing physical and those managing behavioral health services) were eligible for performance incentives based on their joint efforts to identify individuals who could benefit from intensive care coordination, development of integrated care plans, real-time notification of hospitalizations across systems, and medication management. The local pilots used this framework to build out new models of integrated care – for example, embedding nurse “navigators” in community mental health clinics to work on wellness goals and coordinate individuals’ medical care. The pilots demonstrated statistically significant reductions in mental health hospitalizations, all-cause readmissions, and emergency department visits. Consumer surveys also revealed substantial increases in quality of life.
  • Globally, the Programme for Improving Mental Health Care (PRIME) is a consortium of research institutions and Ministries of Health in five countries in Asia and Africa (Ethiopia, India, Nepal, South Africa & Uganda) with partners in the UK and the WHO. The goal of PRIME is to generate world-class research evidence on the implementation and scaling up of treatment programs for priority mental disorders in primary and maternal health care contexts in low resource settings.
  • The Center for Global Mental Health is a collaboration between the London School of Hygiene and Tropical Medicine and King’s Health Partners (incorporating King’s College London), including the Institute of Psychiatry and three of London’s most successful NHS Foundation Trusts.
  • Vikram Patel and colleagues in India provide mental health services in local communities through lay counselors via the nonprofit Sangath.
  • In 1995, Cuba rolled-out “day hospitals” which are community-based outpatient psychiatric services where people with severe mental disorders can stay during the day but not require hospitalization. Individualized, integrated care is provided and allows patients to live at home.
  • In Haiti, Partners In Health/Zanmi Lasante provides community-based mental health services in the Central Plateau region with a team of psychologists, social workers, physicians, and community mental health workers who are regularly trained and mentored.
  • In Rwanda, Partners In Health’s mental health team has developed a system of supported supervision currently being implemented by district mental health staff. Primary care nurses at health centers care for patients with mental disorders, with close and careful supervision by government psychiatric nurses who are district-based and provide referral services for complicated patients. Care and supervision is therefore provided by existing human resources in the care system without duplicating provider roles.

Payment schemes and challenges in the U.S.

  • “No reimbursement system has been subjected to experiment; no evidence exists as to which reimbursement system may most effectively support integrated care.” (AHRQ. October 2008. Report No.: 09-E003.)
  • Payment models (e.g. fee-for-service; case rates; capitation; blended capitation; incentive pools/shared savings; percent of premium) affect how care is delivered which can limit integration.
  • While payment models vary, most entail some form of “per member per month” capitated payment.
  • Administrators should be offered more education and support to review and negotiate contracts so that patients can be provided with better options.
  • Behavioral health is often covered as a separately managed benefit, with implications for who has the right incentives to support integrated service models in both primary care and behavioral health settings. The U.S. also has strong privacy protections for behavioral health information, which can constrain some efforts to integrate care at a population level.
  • Mental health carve-outs and fee-for-service models challenge providers to practice an efficient integrated model as they tend to come with many embedded qualifiers and state-specific limitations through Medicaid/Managed Care Organizations (MCOs) rules such as prohibitions on same-day billing for two services (such as medical and behavioral encounters), or the restriction of certain Current Procedural Terminology (CPT) code sets that would better encourage a blended model.
  • Other issues include when a claim is rejected because of an invalid diagnosis usually attributed to a behaviorist using a medical diagnosis, or when MCOs don't credential behavioral providers.
  • The ACO model represents the possibility to align payer incentives with outcomes and could thus advance integration and comprehensive models of care.
  • In terms of funding of integrated care, the following are often seen as “building blocks”: Same day billing (efficiencies for both the patient and payer); health and behavioral assessment/intervention CPT codes (96150-55); placing a value on consultation and case coordination; per-member/per-month (PMPM) care management rates; and global funding streams.
  • The ACA is now providing a new option to create “health homes”, which aims to extend the patient-centered medical home concept to include behavioral health providers and to increase the focus beyond medical care to include behavioral health and other social support services. States like Iowa, Missouri and Maine are using this model to bring behavioral health professionals into primary care settings to provide care management/care coordination.

Advocacy, Treatment Supporters and Peers, Health IT Tools

  • Raising awareness, understanding of and education on mental disorders are key factors in fighting stigma and improving the quality and availability of services.
  • Peer support groups for people with mental illness offer a much-needed opportunity for socialization. Many affected by mental illness feel ostracized.
  • In the U.S., there are still many who do not seek treatment for mental disorders because they lack insurance.
  • Given the high demand for instant communication, shared information, and data collection and reporting in integrated approaches, the use of electronic medical record systems is almost a requirement.
  • Electronic consultation services are on the rise and states are slowly recognizing the cost saving and other qualities of these services. Project ECHO at the University of New Mexico builds the capacity of primary care teams to treat a more complex array of conditions in their setting, usually for underserved populations, via telemedicine. It has shown clinical outcomes in the community that are equivalent to those achieved by academic medical centers, and its model is being replicated across the U.S.
  • In Haiti, Partners In Health is in early planning stages to pilot a cell-phone interface to help community health workers refer and track outcomes. Other examples of such cell-phone based interfaces for non-specialist mental health care exist in low-resource settings.

Key References

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