At least one in every five adults suffers from mental illness each year. And patients living with serious mental illness face an increased risk for chronic health conditions and shorter lifespans, many times due to treatable causes.
Primary care practices can play an increasingly important role in helping patients address their mental health issues by integrating mental and behavioral health care. Using this approach, primary care teams and behavioral health specialists work side-by-side, sharing patient medical records, treatment plans and overall care management.
To get this message out, the Health is Primary(healthisprimary.org) campaign from Family Medicine for America's Health(fmahealth.org) focused its efforts in May on promoting mental health and its integration into primary care.
As part of this "mini-campaign," Health is Primary released a tear sheet on mental health(healthisprimary.org) that family physicians can provide to patients. This resource defines mental health and mental illness; offers indicators of mental health; and discusses emotional health, including the effects of stress and anger, as well as anxiety and depression.
- The Health is Primary campaign from Family Medicine for America's Health focused its efforts in May on promoting mental health and its integration into primary care.
- In 2010, the department of family medicine at the University of Colorado School of Medicine conducted a case study called Advancing Care Together that examined the attempts of 11 primary care practices at integrating behavioral health care.
- Frank deGruy III, M.D., chair of the family medicine department at the University of Colorado School of Medicine in Aurora, said the principal barrier to integrated care is payment and called for payment reform.
FP Discusses Importance of Integration
Frank deGruy III, M.D., chair of the family medicine department at the University of Colorado School of Medicine in Aurora, told AAFP News that because about two-thirds of primary care patients have behavioral problems, integrating mental and behavioral health into practice just makes sense.
"There is not a simpler single gesture that we can make than to include in the normal fabric of primary care behavioral, psychological, psychosocial, mental, psychiatric and substance abuse health care," he said. "If we are trying to make primary care better, this is one of the best ways to do it."
According to deGruy, it's his responsibility as department chair to ensure that as the department builds new practices and expands its footprint, it does so by offering care that includes behavioral health clinicians and behavioral health care.
The model of integration at the University of Colorado generally includes a family physician (or possibly a nurse practitioner) and a behavioral health specialist, such as a psychologist, working together with a care manager who helps coordinate the care these two clinicians provide.
"These two work together as a team, either of which might be primarily responsible for seeing a patient and taking care of their needs," deGruy said.
The duties of the primary care physician and behavioral health specialist often overlap. "We have behavioral clinicians who know how to make sure somebody gets their immunizations or comes back for a retinal screen if they're diabetic," he said. "We also have family docs who know how to screen for depression and start a second- or third-line antidepressant."
The family medicine department offers a psychology internship, an addiction medicine fellowship and a postdoctoral program for psychologists to train these behavioral health clinicians as part of a primary care team in a primary care setting. He said otherwise, they are trained completely differently.
"For example, if you are a clinical psychologist, you will be trained in a setting that people come to see you for their psychiatric problems," deGruy said. "They'll see patients for 50-minute visits, 12 times or longer. At the end of that, they may be done and the patient leaves the practice."
However, in the primary care setting, he said, the behavioral health clinician might be discussing patients with nurses and the care coordinator and the family physician can come grab him or her to see a patient in the exam room. "They'll see somebody for 10-15 minutes and figure out (the patient) will need to be seen three or four more times for quick rounds of problem-solving therapy to decompress their symptom pressure," deGruy said.
Such a practice setting for behavioral health specialists means many more interruptions and on-the-fly problem-solving, making each day's work completely different.
"This type of care is much more comprehensive, it's much more rewarding for clinicians to provide this type of care, and patients feel like a lot more of what's going on gets taken care of," deGruy said.
Colorado Integration Program Finds Success
According to deGruy, integrating behavioral health care into primary care is "beginning to go viral." But in his department of family medicine's residency training practice, such integrated care has been a priority for many years.
For example, in 2010, the university's department of family medicine conducted a case study called Advancing Care Together that examined the attempts of 11 primary care practices -- ranging from practices at Denver Health and Hospital or Kaiser Permanente Colorado to solo and rural practices -- to integrate behavioral health care. The results were disseminated in a series of articles published in a supplement to the September-October 2015 issue(www.jabfm.org) of the Journal of the American Board of Family Medicine. The family medicine department administered the project, which was sponsored by the Colorado Health Foundation, and gave the practices technical support to facilitate the changes.
"All 11 of them succeeded, and they're still doing it," deGruy said. "That demonstration project was such a success that we now have a statewide project in Colorado. We just enrolled 100 primary care practices to transform to integrated care, and over the next five years, we're going to increase that number up to 500 primary care practices. And all of the payers in the state of Colorado have agreed to pay for this."
One of the things deGruy said he learned from this project was the practices that succeeded most completely at integrating behavioral health care did so by making sure the medical and behavioral clinicians "bump into each other" regularly and are available to work with each other all the time, every day. This, he added, requires close physical proximity.
The researchers also discovered the best methods for communication in this model. "There is a need to have huddles and care management discussions and to share an electronic health record and talk to each other on the telephone and in person a lot," said deGruy.
Another important lesson was that the integration process takes longer than it looks and is harder than imagined. "What we discovered is changing the workflows of practices, changing the cultures so that the behavioral and medical clinicians were thinking and talking the same, changing the way payment and schedules worked -- that is really hard," he said.
Elements Critical to Integration Efforts
The principal barrier to integrated care, deGruy noted, is payment, and payment reform is needed. "Paying for both the medical and behavioral care must come from one funding stream instead of two," he said. "When you've got separate funding streams, people tend to game the system and they cost-shift and it doesn't work. So payment reform is a key to long-term success."
Next, he said even though it's been demonstrated that comprehensive care that uses a skilled care coordinator costs less and is more effective, time still must be set aside for communication between behavioral and primary care clinicians during business hours.
"And if you don't have the type of leadership that understands this, you will never succeed," deGruy said. "You have to get buy-in from leadership that (time for communicating) is an irreducible necessity."
Related AAFP News Coverage
Health is Primary
Campaign Promotes Family Physicians' Role in End-of-Life Care