What is the challenge?
Integrating care for mental, behavioral and psychosocial issues into primary care has become increasingly important. Many patients come to primary care seeking relief for physical symptoms that are related to mental, behavioral and psychosocial problems. Alternatively, illness can lead to depression, stress or other behavioral health issues. These problems generate both acute and chronic challenges for a busy practice. Mental or substance abuse disorders require close follow-up and evidence-based adjustment of treatment to reach clinical targets. Acutely distraught, agitated, or even violent patients regularly appear in primary care. Without ready access to behavioral health expertise, primary care providers and staff often feel unprepared to meet the needs of these patients, and may have to disrupt their clinic schedule and call for emergency assistance.
What needs to change?
Most primary care practices treat behavioral health as another consultative specialty accessed by referral. Relying on referrals to unaffiliated behavioral health providers, however, all too often leads to no-shows and communication and care coordination problems. For patients with mental health or substance abuse problems, outcomes are best when primary care and behavioral health integrate their care to:
- Provide collaborative care in primary care for patients with chronic mental health/substance abuse problems.
- Ensure ready access to assessment and management for patients in crisis.
- Provide brief counseling for individuals who may need additional support for episodic issues.
There are many different ways to configure the behavioral health services of a primary care practice. Considerations include the morbidity and needs of the patient population, the nature of community resources, and reimbursement opportunities for behavioral health providers. A major decision is whether to co-locate or rely on relationships with outside BH providers.
Integrated services can be achieved by collaborative care arrangements with outside psychiatric/substance abuse consultants or by adding behavioral health provider(s) to the primary care practice team. Whether the behavioral health provider is located in the clinic or in an outside organization, full integration with primary care must include sharing care planning and health records; agreement on care pathways and guidelines; and ready access for patients with acute needs.
What do we gain by making these changes?
Practices that successfully implement collaborative care for depression and other chronic mental health disorders consistently report much higher rates of remission and recovery. Readily available and predictable crisis management services for distressed patients, whether by full integration, co-location, or via agreement with community-based behavioral health service providers, can give patients timely access to mental health expertise and provide relief for busy primary care teams. However, patients may be reluctant to seek help for behavioral health related issues for a number of reasons, including:
- Stigma associated with seeing a behavioral health specialist.
- Absence of insurance coverage for behavioral health services or lack of knowledge about benefits, due to complexity of how behavioral health benefits are administered in many organizations and/or states.
Having a behavioral health specialist integrated into primary care teams addresses many of these patient barriers. For example, patients are able to be seen at their primary care clinic, a location that does not specialize in mental health treatment and therefore reduces stigma and increases the patient accessibility to care.
Furthermore, there are many benefits to the team in having access to the consultation of a behavioral health specialist, both to boost the capacity of staff members to address behavioral health issues, and to support the primary care staff and teams to ensure healthy interpersonal relations and a supportive work environment.
Define the behavioral health needs you want to address.
Behavioral health encompasses a wide array of services. Each practice organization needs to define the scope of behavioral health needs it wants to address in an integrated fashion. Does the practice feel confident that it can efficiently deal with acutely distressed patients? Is substance abuse expertise critical for your population? Does the scope include behavior change, like smoking cessation, improving medication adherence, goal setting for healthy eating and improving physical activity, or meeting common social needs? Nonetheless, essentially all primary care practices must have integrated strategies in place to effectively and efficiently deal with acutely distressed patients, and manage patients with chronic psychiatric disorders such as major depression.
Choose a behavioral integration strategy.
How a practice tries to integrate behavioral health expertise will be influenced by practice size, payment options, patient population needs, and behavioral health resources in the community. Practices need to select behavioral health specialists and organizations with whom to collaborate, as well as the level of integration. Many practices find having a behavioral health specialist on-site attractive and reassuring because it facilitates warm handoffs. In addition to having a behavioral health specialist who can provide patient counseling (such as a masters-level therapist or psychologist) and potentially an addictions counselor, most practices will also need a psychiatric consultant for consultation on psychotropic medication management (a Psychiatrist or Psychiatric Nurse Practitioner). Consultation may not involve direct contact with the patient, as long as behavioral health specialists are willing to work in non-traditional ways with non-traditional payment arrangements.
Regardless of the approach, integrated care must also include a shared commitment to measurement-driven, treat-to-target care for chronic problems (see Step 3), as well as interactive communication and sharing of care among behavioral health and primary care providers. Choose a model that fits your organizational and community resources, but remember the importance of proximity and availability.
Enhance the capacity to provide evidence-based, collaborative care.
To provide evidence-based collaborative care, the primary care team should have:
- Explicit guidelines for the treatment of chronic mental health/substance abuse disorders, and standing orders that enable appropriate members of the care team to deliver evidence-based treatment and act independently.
- The capability to provide care management services to patients.
Collaborative care is delivered by a team that includes the patient, the primary care provider, a care manager, and a Psychiatric consultant. The Care Manager supports the primary care provider by coordinating treatment, regularly monitoring treatment response, and alerting the provider when the patient is not improving. The professional background of the Care Manager varies depending on the staffing of the primary care clinic and the treatment regimen. RN and behavioral health specialist care managers can also evaluate and influence treatment, and facilitate communication with the psychiatric consultant regarding treatment changes. Behavioral Health specialist care managers can further add psychotherapy to the treatment regimen.
Develop the capacity for warm hand-offs.
Nearly all LEAP sites found value in being able to obtain timely assessments and short-term therapy from co-located or affiliated behavioral health specialists. Some ways to foster warm handoffs include:
- Developing schedules for behavioral health providers that allow for regular breaks between appointments—for example, 30 minutes with a scheduled patient, then 30 minutes open.
- Having a behavioral health provider sit with the primary care team.
- Introducing the behavioral health provider to patients by phone.
Train as a team.
High-quality integrated care requires effective teamwork with: clear roles and work processes, shared expectations and protocols, and effective communication approaches. It’s important to bring all members of the team together for training and discussion about working together. This is especially important for the primary care provider, behavioral health specialist, care manager, and psychiatric consultant to train as a team around collaborative care processes. The goals of their training include: agreement on treatment, treatment targets, assessment methods, and follow-up; criteria for hand-offs; and guidelines and strategies for communication.
Track patients and measure behavioral health outcomes.
Tracking treatment and outcomes over time in patients with common disorders such as depression gives practices the information needed to treat to target. By measuring patient outcomes, providers can adjust therapy to reach clinical goals. The first steps are to:
- Create a registry of patients needing behavioral health services.
- Develop quality improvement measures and a process for monitoring behavioral health patients.
- Meet regularly as a team to review outcomes for behavioral health patients.