Framework
What is primary and behavioral health care integration (PBHCI)?1
PBHCI is an approach to providing care – whether providing behavioral health services in primary care, or primary care in a specialty behavioral health setting.
PBHCI is also about the culture of an organization – the manner in which its staff practice and work together, and the values of patient and family centered care that are translated at all levels of the organization. Ideally, it encompasses a spectrum from early preventive identification and treatment to tertiary and specialty care.
What makes the integration of primary care and behavioral health so important?2
Rising health cost is one of the greatest threats to economic recovery.3 Yet until now, cost has not been tied to how well providers are achieving desirable outcomes.4
Untreated or poorly treated mental illness and substance abuse are major contributors to spiraling health costs, poor health outcomes with pervasive, difficult to treat illness and in a small subgroup, impulse dyscontrol and/or violent behavior.
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The absence of judicious screening in primary care as well as specialty settings lays the groundwork for late stage identification of these conditions.
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Equally important is the lack of integrated treatment to address often co-occurring factors – emotional, psychological and social (by which we include family, community and other supports) as well as medical components. By addressing these factors at the same time, we assure consistency of care, coordination and improved outcomes with reduction in cost.
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Knowing when to refer to specialized behavioral health care is critical to successful, cost-effective outcomes.4
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Similarly, lack of access to primary care for people with serious behavioral illness has created a major health disparity for these vulnerable populations across all socioeconomic lines.
The result? Often intractable, serious behavioral illnesses combined with chronic physical conditions that have reduced life expectancy by several decades and massively escalated the cost of caring for these vulnerable populations.5 Healthcare occurs within a community landscape, unique for each provider and system. There is no substitute for a healthy community, including housing and other natural supports. The lack of affordable housing is a major factor in the escalation and costs attached to complex, chronic illness. Addressing these issues requires that we recognize the reciprocal relationship between investment in social and housing supports and health costs.6
An urgent call has now been made through a series of reports and white papers cited as well as others that primary care and behavioral health become integrated. The research base on best practices is incontrovertible: integration makes sense in terms of the Triple Aims of quality, cost and satisfaction for patients, families and providers.
In 2008 the Affordable Care Act7 spelled out that reimbursement for health care, previously driven by procedures and volume, must now be driven by performance and outcomes. This requires a major commitment to changes in function, design and management through medical homes and accountable care organizations (ACOs).
How does PBHCI relate to Medical Homes and Accountable Care Organizations?8
PBHCI is central to the medical home concept of multi-disciplinary teams working with patient, family and community. Yet, this type of practice requires a significant departure from the clinical practice, training and administrative structures that have supported and maintained the siloing of services in most settings.
Most organizations have neither staff experienced in these new functions, nor the organizational culture to create and implement the necessary changes. Training of staff as well as new administrative, financial, IT and QI processes are needed to sustain primary and behavioral health care integration and to assure its accountability.
What is the impact of our separated systems on workforce readiness for PBHCI?
The separation or ‘siloing’ of clinical practice and support structures for mental health, substance use and primary care has resulted in clinical and administrative staff acclimated to these divisions along with the frustrations that accompany them. This applies as much to the delivery of care and problem-solving as to the documentation of care, data collection, problem-solving, and the support functions that maintain these siloed operations.
Yet, articulating policy is one thing, making it happen requires the human resources to implement that policy. Staff skilled in PBHCI are in short supply.
At Integrus Health Group, our major focus is two-fold:
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To assure that primary care populations have access to quality behavioral health services – mental health and substance use services – and
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To similarly assure that people with serious behavioral conditions have access to timely and quality primary care.
For all populations, we endorse and advocate for much earlier identification, intervention and prevention of these conditions
This requires implementation of best practices together with a spectrum of innovations and system changes. These may include behavioral health services becoming ‘embedded’ within primary care settings, primary care moving into or more closely aligning with specialty behavioral health settings and variations on this, depending on local conditions.
Principles underlying PBHCI
Integrus Health Group recognizes that:
A number of principles are important for the successful transformation into PBHCI, which is central to whole person care, the medical home and seamless coordination. We know first-hand that –
- Blueprints developed at 30,000 feet must be translated to the ground level of operations, with the success or failure of health reform needing to be judged at the front end of the system -- where practice becomes policy – and policy meets providers, patients, families and communities.
- The continuum from preventive and primary care to specialty behavioral health care should address PBHCI in each setting. PBHCI is best adapted to the specific setting within which it is operating, whether mental health and addiction services adapted to a fast-paced, high-volume primary care environment or, primary care adapted to a specialty behavioral health setting that serves the seriously mentally ill and substance-using populations.
- Screening for high-risk conditions is a necessary first step, but insufficient in and of itself.
- Prevalence of co-occurring conditions is by far the norm rather than the exception, depending on the population and setting. This may entail two or more diagnoses within behavioral health itself and often one or more within the physical health realm.
- Improving access calls for ‘on demand’ services is a must. On-site care should be provided for a range of conditions to assure minimal interruption in services, with expedited referral to a higher level of care to assure continuity. This entails embedding of behavioral staff in primary care settings, primary care staff in specialty behavioral health services as well as cross training of providers.
- When implemented with adequate training and support, the use of peer counselors and family advocates improves engagement and outcomes. Very simply, it is one of the major forward steps in an evolving field.
- The use of broader preventive interventions, including nutrition, exercise, stress reduction through meditation, cognitive therapies to effect behavioral changes, acupuncture and chiropractic among others can significantly reduce the over-reliance on costly procedures and pharmaceuticals.
- Problem solving, especially around the higher-risk, more complex individuals, takes on a new dimension within formal conferencing and curbside consultation. This draws upon varied data sources while maintaining strict compliance with HIPAA and other federal and state laws.
- Tracking and measurement of PBHCI progress requires data collection and analysis across traditional service and IT sectors, generally between physical health, mental health and substance use at a minimum.
- Emotional and spiritual health remains a critical component of care and wellness for the whole person and family. Considerable work can and should be done without requiring that a diagnostic threshold be reached to achieve the best outcomes and to avoid unnecessary services and costs.
Institute on Medicine’s 2001 “Crossing the Quality Chasm: A New Health System for the 21st Century”
The National Council’s 2003 background paper on “Behavioral Health/Primary Care Integration Models, Competencies and Infrastructure”
MacArthur Foundation Public Policy Paper: Integrating Mental and Physical Health Care to Better identify and Treat Depression, John Williams, Jr and Allen Dietrich
Colton CW., Manderscheid RW.. (2006, April). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease: Public Health Research, Practice and Policy. 3(2), 1-14.
Elizabeth H. Bradley and Lauren Taylor, Op-Ed NY Times December 9, 2011
The 2008 Affordable Care Act
The Medical Home Model: Jonathon Amiel, Harold Alan Pincus: Curr Opin Psychiatry. 2011; 24 (6): 562-568
