My patient Andrew was brought to my office by his parents. They were concerned that his attention deficit hyperactivity disorder (ADHD) medication had not been as effective in the last few months as in the past. During the visit I learned that there had been recent changes to the parents' custody agreement and that Andrew's father was going through a second divorce. Andrew had become sullen and argumentative and less willing to do homework. His grades were faltering as well.
Primary care physicians deliver half of all mental health services (92 percent among the elderly),1 perhaps in part because patients prefer to seek behavioral health care from their family physician to avoid the stigma and unfamiliarity of a therapist's office or mental health facility.2 Whatever the reason, there is no shortage of cases like Andrew's in family medicine, where we find that a patient's mental health is directly linked to his or her physical health. Consider a case in which a patient is spiraling downward with depression despite medical intervention, or an adolescent shows the first signs of psychosis or mania, or a patient's substance abuse problem complicates treatment of other medical conditions. What do you do for these patients, and for Andrew?
Increasingly, family physicians are finding that the best answer to the above situations is to collaborate closely with a behavioral health specialist or integrate one into their practice.
Finding the right level of integration
The level of collaboration between a family physician and a behavioral health specialist can vary from rudimentary (e.g., developing a preferred referral relationship with a local caregiver) to fully integrated, which requires an operational, structural and financial transformation of the practice. Consider these five levels of collaboration:3
Level 1: Minimal collaboration (referrals only),
Level 2: Collaboration at a distance (referrals and some direct communication),
Level 3: Basic on-site collaboration,
Level 4: Close collaboration in a partly integrated system,
Level 5: Close collaboration in a fully integrated system.
Many family physicians work in settings with level 1 or level 2 collaboration. Typically, these practices refer patients to a preferred behavioral health specialist, such as a psychotherapist. Minimal collaboration is often sufficient for cases that do not involve psychotropic medications, family therapy or specialty care such as court-mandated therapy or inpatient substance abuse treatment.
The advantages of level 1 and level 2 collaboration for family physicians are that treatment does not stray far from familiar physician skill sets and minimal resources are required. However, these levels of collaboration require extra work on the part of the patient, and they often result in high no-show rates and a disconnect in planning and coordinating care.
At the other end of the scale, highly integrated arrangements (i.e., those with level 4 and level 5 collaboration) are becoming increasingly common. While such arrangements were originally conceived for specialty clinics such as cancer and HIV treatment centers, many private practice physicians and their patients are now benefiting from them. Common characteristics of highly integrated systems include on-site, full-time mental health staff; integrated medical records and billing; universal screening for depression and substance abuse; and a focus on treatment approaches that encourage shared patient care. These arrangements also create opportunities for the family physician to personally introduce the patient to the behavioral health specialist and for “meet-in-the-hall” consults and shared appointments for more complex cases.
Issues of cost and space make it difficult for practices to move forward with level 4 or level 5 integration. Many family physicians find it most practical to pursue a basic collaboration (level 3), in which the behavioral health specialist conducts an independent practice in the physician office, simply entering into a contract with the practice for space and the use of its staff. Most behavioral health specialists are self-sufficient and require only one room and limited use of front-desk staff. (We realize that even this small amount of space may be more than a practice has available. You can see in the case example below that full integration did not happen for Primary Care Partners until the practice changed locations. This may be the case for many practices.) Collaboration occurs as the need arises. As the relationship grows, billing services and even patient records might be shared. Of course the financial impact on the family medicine practice is entirely dependent on the contracted arrangement.
A CASE EXAMPLE: PRIMARY CARE PARTNERS
Primary Care Partners is a group practice in Grand Junction, Colo., with 21 family physicians and 14 pediatricians. To better manage the behavioral needs of our patients, we began collaborating with a local private counseling group about 12 years ago. Over time their staff began to commute to our office for joint patient appointments.
In 2004, Primary Care Partners moved into a new building that allowed us to rent space to the mental health group. They now share a waiting room with our family physicians. Our proximity promotes daily shared patient care including joint visits, curbside consults and availability for emergent evaluations in both offices.
In 2009, a family physician and pediatrician in our practice completed a six-month integrated care certificate program with a psychologist and family therapist from the mental health office. Since then, the mental health office has fully embedded a counselor in our pediatric office. Our physicians have continued to develop this relationship, and because of this, patients in crisis can have an immediate intervention with the on-site mental health staff. The integration makes accurate diagnosis and medication management much easier because it is supported by a thorough work-up and ongoing consultations by a behavioral health specialist. We have seen patient satisfaction increase because of the integrated therapeutic relationship of physicians and behavioral health specialists and the care that they offer. And last, our mental health care partners save the physicians time by continually providing us with updated patient records.
Some physicians express concern that integrated systems may violate laws against self-referral. Federal Stark laws are the primary issue; however, Stark laws apply to a very specific set of services (i.e., laboratory, radiology and home nursing) that does not include mental health services. State laws may set a higher standard and should be consulted. Regardless, it is wise to maintain relationships with numerous behavioral health specialists because patients' needs and preferences may require services beyond what the provider you typically collaborate with can offer.
If a behavioral health specialist is working in the practice's space, it is important to address patient confidentiality. To ensure Health Insurance Portability and Accountability Act compliance, many offices choose to have shared patients sign a consent-for-treatment form that covers release of information and explains that the behavioral health specialist and the physician will share information for continuity-of-care purposes.
It is important for physicians to keep in mind that, while physicians are able to bill for almost all encounters that involve a behavioral health specialist, the reverse is not always true. Behavioral health specialists cannot always bill for services that involve a physician. This can make it more difficult to sustain a collaborative practice.
Finding the right specialist to collaborate with
Behavioral health specialists cover a variety of specialties and differ in their training and licensure. Professional counselors, family therapists and clinical social workers provide the majority of collaborative services with family physician practices. These professionals are typically trained at the Master's degree level and are qualified to treat conditions commonly found in a primary care setting, such as depression, anxiety, ADHD, relationship problems and insomnia. Depending on the demographics and health needs of your patients, professionals with different training may be a good fit. These include certified addictions counselors for patients with alcohol and drug problems, psychologists for diagnostic testing and other treatments that require advanced training, group therapists for co-leading group medical appointments for chronic illness or prenatal care, and case managers for assisting patients in accessing community resources, such as housing assistance, referral to specialists, legal aid, pharmaceutical assistance programs and applications for disability.
Weighing the benefits
The positive outcomes that an integrated behavioral health specialist can bring to you, your practice and your patients are plenty (see “A case example: Primary Care Partners”). We've experienced the following benefits of collaboration, but you may find additional benefits in your own practice:
Increased efficiency. Chronically ill patients with co-occurring somatic or mental health issues can be quickly sent to an in-house behavioral health specialist without a referral or scheduling a separate appointment. All the while, the physician is able to remain on schedule.4
Improved health outcomes. Working as a team, the physician and behavioral health specialist assist the patient in managing chronic illnesses that often require changes in lifestyle and behaviors.7
Improved mental health outcomes. Research shows that patients with mental health conditions achieve greater symptom relief and have less need for costly emergent services when treated by an interdisciplinary team.8
Let them help you
Let's return to Andrew's case:
A behavioral health specialist can be a “helpful neighbor” who visits or shares space within a family physician's practice. He or she can assist with the treatment of patients' mental and behavioral issues, which might otherwise tie up a physician's time and detract from those aspects of care that a family physician finds most professionally, personally and financially rewarding.
KEYS TO SUCCESS
We have identified a few key tips that can help physicians make integrated arrangements smoother and easier for staff and patients.
Pay attention to location. Physician and behavioral health specialists' offices should be close together. This makes it easier to share medical records and helps promote availability, frequent interaction and shared patient care. We recommend the “bathroom rule,” that is, offices should be close enough that everyone shares the same bathroom.
Institute an “open door” environment. Providers should be willing to be interrupted to assist one another. Although this kind of “open door” environment may be foreign to traditional practices, it is commonplace in integrated settings as it facilitates quick introductions, medication management and updates.
Share tools. Sharing paper or electronic tools can improve diagnostics, communication and patient tracking. These should include a health history and screening tools, such as the PHQ-9 tool for assessing depression (available from American Family Physician at https://www.aafp.org/afp/2008/0715/p244.html) and the “Immediate Action Protocol” for patients at risk of suicide (available from FPM at https://www.aafp.org/fpm/2009/0900/p17-rt1.pdf), and a flow sheet for tracking depression scores, medications and other mental health data over time.
Simplify the patient experience. Ideally, the patient experience should not vary based on which provider he or she is seeing. Check in, check out and payment should be the same whether seeing a physician or behavioral health specialist.
Develop a trusting relationship. Physicians and behavioral health specialists should meet regularly over lunch or coffee to discuss operational and clinical issues. This encourages open and honest communication and support of one another.
Seek additional training. Collaborative Family Healthcare Association's Annual Conference is a three-day event that offers dozens of workshops geared to both physicians and behavioral health specialists. Visit http://www.cfha.net/pages/Conference for more information. The University of Massachusetts Medical School Certificate Program in Primary Care Behavioral Health consists of six full-day workshops over six months that include presentations and interactive learning. Enrollees can participate on site or by webinar. Visit http://www.umassmed.edu/PCBH.aspx for more information.