Bridging the Gap: Integrating Primary and Behavioral Health Services

Andrew Philip, PhD, Deputy Director, CIHS Brie Reimann, MPA, Director, CIHS

w w w . T h e N a t i o n a l C o u n c i l . o r g

National Council for Behavioral Health

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•  Advocacy •  Education •  Technical Assistance:

SAMHSA-HRSA Center for Integrated Health Solutions (CIHS)

2900 Behavioral Health Organizations

2 .M 4.5% 22%

2 .M 4.5% 22%

Group Learning Experience: Regional and Online Learning Communities Cross-site TA Trainings and Peer Learning Tools: Web-based Tools and Resources Issue Briefs Webinars Curated Content Integration Edge Individual Technical Assistance: Phone and video consultations, e-mail, site visits

Integrated Care Defined

The care that results from a practice team of primary care and behavioral health clinicians working with patients and families, using a systematic and cost-effective approach

to provide patient-centered care for a defined population.

In the US, about:

•  1 in 5 adults experiences mental illness •  18% experienced an anxiety disorder •  7% experienced one major depressive episode

•  1 in 25 adults experiences a serious mental illness •  2.6% of adults live with bipolar disorder •  1.1% of adults live with schizophrenia

•  1 in 5 youth aged 13–18 experiences a severe mental disorder at some point during their life

•  Among the 20.2 million adults who experienced a substance use disorder, 50.5% had a co-occurring mental illness National Alliance on Mental Illness (NAMI)

Current Issues and Trends

•  The Opioid Epidemic will shine light on BH services •  Certified Community Behavioral Health Centers (CCBHC) demonstration is

underway •  Medication Assisted Treatment •  Trauma Informed Care •  Financing Reform

Primary Care Settings High prevalence of a range of behavioral health conditions

•  Anxiety, •  Depression, •  Substance use in adults •  Anxiety, •  ADHD, •  Behavioral problems in children (Prevention and early intervention opportunity)

People with common medical disorders have high rates of co-morbid behavioral health conditions

•  Diabetes, •  Heart disease, •  Asthma with depression (Worse outcomes and higher costs if both problems aren’t addressed)

The Need for Integrated Care •  60% of adults and 70% of children get

NO MH care •  Depression is the 3rd most common

reason for a visit to a health center after diabetes and hypertension

•  Suicide is a major public health issue •  Visits to emergency rooms involving the

misuse of prescription drugs have doubled in the last five years

•  Mortality rate is increasing among people with serious mental illness to 20-25 years earlier than general pop.

•  1/2 of all care for common psychiatric disorders happens in primary care settings

•  Populations of color are even more likely to seek or receive care in primary care than in specialty behavioral health settings

•  Primary Care and ED settings are not prepared to adequately address mental health disorders

•  Achieve the Triple Aim: lower costs: improve health outcomes and improve patient satisfaction

BH Integration in Primary Care Includes: •  Universal Screenings (MH/SU/Suicide/Trauma) •  Clinical teams with embedded behavioral health clinicians •  Prescribing with Psychiatric consultation •  Medication assisted treatment for substance use disorders •  Treatment plans that include mental health/recovery goals •  Wellness services •  Quality Improvement Measures •  Community Linkages

What can integration look like? •  Behavioral Health Consultants (BHCs) work alongside primary care

providers (PCP) and make recommendations to the PCP. •  Immediately accessible for both curbside and in-exam room consults,

same-day visits (15 – 30 minute consultation), prevention education/anticipatory guidance.

•  Shared records: Chart in the medical record using a SOAP note format. •  No office, No Caseload, No “no shows” Robinson,P.J.andReiter,J.T.(2007).BehavioralConsulta=onandPrimaryCare(pp1-16).N.Y.:SpringerScience+BusinessMedia.

Heath B, Wise Romero P, and Reynolds K. A Review and Proposed Standard Framework for Levels of Integrated Healthcare. Washington, SAMHSA-HRSA Center for Integrated Health Solutions. March 2013

The Case for Integration: Cost Savings •  Numerous studies have revealed cost savings with regard to decreased

use of ED and admissions (Lute & Manson, 2015; 10.1007/978-3-319-19036-5_2)

•  19% reduction in ED visits and overall reduction in number of primary care visits (Institute for Healthcare Improvement, October 31, 2008)

•  Individuals participating in primary care depression management experienced a reduction in workplace absenteeism by over 28% (Smith & Dickinson, 2004)

The Case for Integration: Improved Functioning •  Nearly all individuals experience an increase in functioning across studies

•  Also six studies found improvements in: •  Anxiety •  Depression •  PTSD •  Sleep •  Tobacco

(Hunter, 2017; DOI: 10.1007/s10880-017-9512-0)

The Case for Integration: Satisfaction •  Patients in integrated primary care behavioral health settings have

reported high levels (e.g., 97%) of satisfaction and increased functioning (Angantyr, 2015; https://doi.org/10.2224/sbp.2015.43.2.287; Runyan, 2004; https://doi.org/10.1089/109350703322425527)

•  Team-based primary care-behavioral health care has also been shown to improve provider satisfaction and decrease provider burn-out (Blount, 2003; 10.1037/1091-7527.21.2.121)

Integration Tools and Resources (CIHS)

CIHS’ Standard Framework for Levels of Integrated Healthcare helps primary and behavioral healthcare provider organizations improve outcomes by helping them understand where they are on the integration continuum. There are a number of assessment tools designed to help provider planning.

Lexicon for Behavioral Health and Primary Care Integration. Agency for Healthcare Research and Quality Integration Academy

Four Quadrant Model: This model describes levels of integration in terms of primary care complexity and risk and MH/SU complexity and risk.

Integration Tools and Resources (CIHS)

Quick Start Guide to Behavioral Health Integration is an interactive flowchart to walk you through some of the questions to consider when integrating behavioral health care.

The Core Competencies for Integrated Behavioral Health and Primary Care provide organizations and individual professionals a “gold standard” for the skill set needed to deliver integrated care.

Customized Billing and Financial Worksheets for each state to help identify existing billing opportunities for services provided in integrated healthcare settings

Lessons Learned - Check out the eSolutions on Lessons Learned from Integration Pioneers or view the webinar to hear from SAMHSA Primary and Behavioral Health Care Integration (PBHCI) grantees who have taken on the task of integrating primary care into their services.

CIHS Tools and Resources Visit www.integration.samhsa.gov or

e-mail integration@thenationalcouncil.org

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