[NYAPRS Enews] Primer on Integrating Primary/Behavioral Health Care Released

[Harvey Rosenthal]

Primer on Integrating Primary Care and Behavioral Health Care

Psychiatric Services  June 2010

 

A new report from the Milbank Memorial Fund provides a primer on
integrating primary care and behavioral health care. It describes eight
models along a continuum-from minimal collaboration to full
integration-and provides an implementation planning guide. Integration
will be a critical component of health care reform in the coming decade,
the report concludes. It will be driven by redundancies in
administrative and service delivery structures and the current embrace
by health care systems of quality improvement and the concept of the
patient-centered "medical home." These factors, along with the need to
contain costs, are "providing the health care industry with an
extraordinary opportunity to reshape the way behavioral health care is
provided." 

The 88-page report, Evolving Models of Behavioral Health Integration in
Primary Care, ends with a 16-page list of references and selected
readings that attests to the authors' introductory statement: there is a
vast amount of information in the field of collaborative and integrated
care, more than any single document can synthesize. A robust and
burgeoning literature includes seminal work by more than a dozen
prominent leaders, a monograph-length literature review, dozens of
technical reviews covering topics such as financing and program
assessment, several influential books documenting basic concepts,
numerous toolkits and how-to manuals, Web sites offering an array of
resources, two journals covering the field, and a national membership
organization. Rather than synthesize this mass of information, the
report examines salient themes to identify practical implications for
policy makers, planners, and providers of general medical and behavioral
health care. 

Four concepts are common to all models of integrated care: the medical
home, the health care team, stepped care, and the four quadrants of
clinical integration. The medical home has become a mainstream theory in
primary care, in particular for patients with chronic illnesses.
Although it is not specifically an integrated care model, the concept
encompasses the philosophy of integration. The health care team is
deeply seated in the field, the report notes. In integrated care, the
team-patient relationship replaces the doctor-patient relationship, and
a patient's visit is "choreographed" with various members of the team.
Stepped care is widely used in integrated models and refers to provision
of care that is the least disruptive to a person's life; the least
intensive, extensive, and expensive to achieve positive patient
outcomes; and the least expensive in terms of staff needed to provide
effective services. 

The four-quadrant framework identifies the setting in which patients
should receive care on the basis of their needs-from low to high
physical health risk and complexity and low to high behavioral health
risk and complexity. For example, quadrant IV is for patients who have
high needs in both areas, such as individuals with schizophrenia who
have hepatitis C; these patients are typically served in both primary
and specialty care settings, with a strong need for collaboration
between the two. 

Models of integrated care can be organized along a continuum that begins
with minimal collaboration followed by basic collaboration at a
distance, basic collaboration on site, close collaboration in a partly
integrated system, and close collaboration in a fully integrated system.
The report describes eight distinct models while acknowledging that most
initiatives in real-world settings are hybrids that blend elements of
these models. The eight models are improved collaboration, medically
provided behavioral health care, colocation, disease management, reverse
colocation, unified primary care and behavioral health, primary care
behavioral health, and a collaborative system of care. Eight separate
sections provide definitions of each model and describe strategies used
for integration of care. A summary of evidence from randomized
controlled trials is followed by considerations for implementing and
financing the model. Existing programs that use the model are briefly
described. 

For example, practice model 5-reverse colocation-is situated on the
continuum at the point of close collaboration in a partly integrated
system. It reverses the usual approach in which behavioral health care
is integrated into primary care and instead seeks to improve general
medical care for persons with serious and persistent mental illness. A
primary care physician, physician's assistant, nurse practitioner, or
nurse may be stationed part- or full-time in a specialty setting, such
as a rehabilitation program or an outpatient psychiatric clinic. Studies
of this model are in their infancy, the report notes, but early findings
indicate the model's potential to reduce lifestyle risk factors-for
example, through screening for hypertension and diabetes. Implementation
considerations for reverse colocation include how to address issues such
as treatment consents, maintenance of medical records, and referral
processes. Mental health case managers in this model will need to
develop skills to promote wellness and help patients manage medical
conditions. Financial considerations include the potential difficulty of
hiring primary care providers, particularly for uninsured and Medicaid
patients with multiple comorbid conditions. In addition, mental health
agencies may be unable to access codes to bill for medical visits. As an
example of this model, the report cites the Community Support Services
Center in Akron, Ohio, which serves adults with severe mental illness
and which established an integrated primary care clinic and pharmacy in
2008. 

How can policy makers, planners, and providers of care determine which
model is the best for their agency or community? A brief section lists
issues for consideration, such as the primary goals of the initiative,
available resources, and consumer preferences. Because current fiscal
realities in many locales will dictate incremental progress, the report
outlines a tiered approach designed to maintain forward momentum toward
integration, starting with maximizing existing resources, then
investment of new resources, and then significant system redesign. 

The report is available on the Milbank Web site at www.milbank.org.

http://psychservices.psychiatryonline.org/cgi/content/full/61/6/635 

-----------------------

 

Evolving Models of Behavioral Health Integration in Primary Care 

Chris Collins, Denise Levis Hewson, Richard Munger, and Torlen Wade 

Milbank Memorial Fund

Executive Summary   May 2010

 

Mental illness impacts all age groups. The National Institute of Mental
Health (NIMH) states in a 2008 report that an estimated 26.2 percent of
Americans ages eighteen and older-about one in four adults-suffer from a
diagnosable mental disorder in a given year, which translates into 57.7
million people. Furthermore, researchers supported by NIMH have found
that mental illness begins very early in life (2005). Half of all
lifetime cases begin by age fourteen, and three-quarters have begun by
age twenty-four. Thus, mental disorders are really the chronic diseases
of the young. Unfortunately, evidence also shows that the mental health
system fails to reach a significant number of people with mental
illness, and those it does reach often drop out or get insufficient,
uncoordinated care. 

The good news is that research has improved our ability to recognize,
diagnose, and treat conditions effectively. In fact, many studies over
the past twenty-five years have found correlations between physical and
mental health-related problems. Individuals with serious physical health
problems often have co-morbid mental health problems, and nearly half of
those with any mental disorder meet the criteria for two or more
disorders, with severity strongly linked to co-morbidity (Kessler et al.
2005). As cited in Robinson and Reiter (2007), as many as 70 percent of
primary care visits stem from psychosocial issues. While patients
typically present with a physical health complaint, data suggest that
underlying mental health or substance abuse issues are often triggering
these visits. Unfortunately, most primary care doctors are ill-equipped
or lack the time to fully address the wide range of psychosocial issues
that are presented by the patients. 

These realities explain why policymakers, planners, and providers of
physical and behavioral health care across the United States continue to
grapple with how to deliver quality, effective mental health services
within the context of individual well-being and improved community
health status. 

Over the past several decades, examples of coordinated care service
delivery models-those that connect behavioral and physical health-have
led to promising approaches of integration and collaboration. Emerging
evidence from a variety of care models has stimulated the interest of
policymakers in both the public and private sectors to better understand
the evidence underpinning these models. 

Improving the screening and treatment of mental health and substance
abuse problems in primary care settings and improving the medical care
of individuals with serious mental health problems and substance abuse
in behavioral health settings are two growing areas of practice and
study. Generally, this combination of care is called integration or
collaboration. 

Integrating mental health services into a primary care setting offers a
promising, viable, and efficient way of ensuring that people have access
to needed mental health services. Additionally, mental health care
delivered in an integrated setting can help to minimize stigma and
discrimination, while increasing opportunities to improve overall health
outcomes. Successful integration requires the support of a strengthened
primary care delivery system as well as a long-term commitment from
policymakers at the federal, state, and private levels. This report
assesses models of integration in their applicability to primary care
settings and, in particular, to the "medical home." Many of the
challenges and barriers to integration stem from differing clinical
cultures, a fragmented delivery system, and varying reimbursement
mechanisms. 

This report also provides an orientation to the field and, hopefully, a
compelling case for integrated or collaborative care. It provides a
concise summary of the various models and concepts and describes, in
further detail, eight models that represent qualitatively different ways
of integrating and coordinating care across a continuum-from minimal
collaboration to partial integration to full integration. Each model is
defined and includes examples and successes, any evidence-based
research, and potential implementation and financial considerations.
Also provided is guidance in choosing a model as well as specific
information on how a state or jurisdiction could approach integrated
care through steps or tiers. Issues such as model complexity and cost
are provided to assist planners in assessing integration opportunities
based on available resources and funding. The report culminates with
specific recommendations on how to support the successful development of
integrated care. 

Extensive research and literature exist about models of integration. A
resource section at the end of this report provides a list of websites,
toolkits, and other references. 

 

-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://kilakwa.net/pipermail/nyaprs_kilakwa.net/attachments/20100601/30838cf5/attachment.html>