To family physicians who had any remaining doubt about the intertwining of primary care and mental health services, consider these statistics served up by participants in a recent Web-based forum: Half of all behavioral health conditions are treated in the primary care setting, and four out of five patients with a mental health condition will visit a primary care physician within a year. Patients with both chronic care and mental health needs can cost between 150 percent and 300 percent more than patients with a chronic condition alone.
"We're past the point of making a case that integration needs to happen," said Mara Laderman, M.S.P.H., senior research associate at the Institute for Healthcare Improvement (IHI). "It is essential that primary care be able to care for these patients. A lot of financial barriers have to be overcome to make it work."
Laderman spoke during a webcast hosted by IHI(www.ihi.org) that focused on the need for integration between mental health and primary care. Participants agreed that payment reform and integrating team members are among the greatest hurdles to achieving this goal.
"The movement to health transformation with PCMH (the patient-centered medical home) revealed how important it is to build high-functioning, multidisciplinary teams to meet the primary care needs of the population," said Ed Wagner, M.D., M.P.H., director emeritus for the MacColl Center for Health Care Innovation at the Group Health Research Institute of Group Health Cooperative in Seattle.
- Primary care physicians treat a high percentage of patients with mental health care needs.
- Some large medical systems established primary care as the first point of contact for mental health patients.
- Although sometimes challenging, training primary care health professionals to work with mental health specialists benefits patients.
Wagner noted that physician practices need to build in the capacity to provide care for patients with common mental health ailments such as major depression, such as by bringing in mental health experts (e.g., a clinical social worker) to advise the core team.
"In most implementations of the collaborative care model, the psychiatric consultant is outside the practice and provides advice to medical assistants and nurses," Wagner said.
"You don't have to have an on-site psychiatrist. Most of the prescribing is done by a primary care doctor with the advice and support of an outside consultant."
The most innovative physician practices are filling gaps in care by building relationships with individual providers or agencies, said Wagner.
At the St. Charles Health System in Bend, Ore., leaders decided that mental health services needed to be available in primary care. The facility decided to develop an integrated approach that offers mental health services at the first point of contact, according to Robin Henderson, Psy.D., chief behavioral health officer at St. Charles.
Many patients arriving in the ER had mental health issues, she recounted, but emergency staff thought the ER was not an appropriate setting to provide such care. Referrals to mental health specialists were made from the ER or from primary care settings, but patients were not keeping the appointments. The system's leaders decided to start making referrals to primary care as part of an ER diversion project. Doing so meant that the institution had to make connections with health care professionals who are not affiliated with St. Charles, which itself presented some obstacles.
"It is difficult to maintain the infrastructure," Henderson admitted. "We wanted to keep it in the ER, but it needs to be in primary care."
After the advent of the new approach, the health system reported a 65 percent reduction in visits per targeted patient in 2010 and lower overall spending.
Henderson admitted that the integration effort can be tricky because teams that do not traditionally work together are expected to collaborate. She also acknowledged that such efforts may not be well-suited to rural areas because opportunities for psychiatric consultation may be lacking, and the overall level of support for physicians to handle mental health issues is limited.
"It's a roller coaster for us," said Henderson. "Right now, our team is practicing the basics to get comfortable with all of the pieces. Everybody knew their role, but not in a team."
At Cherokee Health Systems in Knoxville, Tenn., medical professionals provide comprehensive care at 60 different clinic locations. Parinda Khatri, Ph.D., chief clinical officer for Cherokee, echoed the sentiments of others who noted that effective behavioral health cannot be isolated from primary care. "If we wanted to provide good behavioral care we had to provide good primary care," she said.
One huge boon, said Khatri, was that the facility's CEO, Dennis Freeman, M.D., was committed to making the integration concept work as it was developing.
"He said, 'Let's get big enough so payers have to listen to us and expand to as many areas as possible,'" she recalled. "Payers had to come to the table. They were open to global payments and a payment for care coordination."
When patients arrive at the facility, they receive comprehensive care from a coordinated team. There is one behavioral specialist on the primary care team, who serves as a consultant entirely dedicated to primary care and does not carry a separate mental health case load. Two consulting psychiatrists are also members of the team.
"The scope of service is expanded much more than it would be in a traditional mental health setting," Khatri said.
The facility makes full use of telehealth and electronic health records for predictive analysis. Patients with complex health needs are identified right away. Behavioral health is a component of all health screenings provided for children.
Besides integrating primary care physicians and the rest of the care team with mental health professionals, the panelists noted that financing for integrated care is not widely established, and no specific payment model that supports such coordinated care exists.
"Given the difficulty in funding, why do it?" Wagner asked. "Because it's the right thing to do. You can't practice competent primary care if you don't meet critical behavioral health needs. It requires cobbling together and being creative."
Related AAFP News Coverage
Robert Graham Center Forum
Speakers Emphasize Need to Build Bridges Between Primary Care, Mental Health