Primary Care and Behavioral Health

Up to 70% of all primary care visits include a behavioral health component. Why not put the two together?

January 2023 – The Journal of Healthcare Contracting

Accessing behavioral health services in the United States is becoming increasingly difficult even as the need for such services keeps growing. Some healthcare decision-makers believe that primary care practices can help fill that void. But can they shoulder the task, given the staffing and reimbursement challenges of behavioral health?

“Integrating behavioral health with primary care aims to increase access as well as reduce the stigma associated with seeking mental health treatment,” says Sterling Ransone, M.D., FAAFP, president of the American Academy of Family Physicians. “Without a system in place to routinely screen for behavioral health conditions and substance use disorder in the primary care setting, we will miss opportunities to address problems that threaten the health and well-being of our patients, families and communities.”

Fifteen to twenty percent of adults in the United States report diagnoses of depression or mental illness, and 10% to 15% report suffering severe psychological distress in the past year, according to a recent report from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, a Washington, D.C.-based clinical research group.

COVID-19 exacerbated the situation. Data from the U.S. Government Accountability Office shows that the pandemic increased social isolation and stress, and contributed to higher rates of anxiety and depression symptoms and increased substance use in the U.S. Yet fewer than 50% of those with a mental illness reported receiving care in the past year.

Makes sense

The close relationship between physical and mental health is an oft-cited rationale for integrating behavioral health and primary care. Up to 70% of all primary care visits include a behavioral health component, write leaders of the Behavioral Health Integration (BHI) Collaborative in a recent issue of “Health Affairs.” Founded in October 2021, the BHI Collaborative is led by several physician organizations and is intended to support physicians working to combine mental and physical health in their practices.

Behavioral health conditions are a leading contributor to disease burden in the United States, with depressive and substance use disorders among the top 10 causes of death and disability among adults. They are also a leading cause of preventable pregnancy-related deaths. Individuals with co-occurring physical and behavioral health conditions also tend to incur higher healthcare costs and experience worse health outcomes.

Undiagnosed and untreated behavioral health conditions often have physical manifestations, according to the Robert Graham Center. Patients with chronic diseases whose mental health conditions are left undiagnosed or untreated often experience poor management of these chronic diseases and worse clinical outcomes.

“Behavioral health is more than just mental health,” says Yalda Jabbarpour, M.D., director of the Robert Graham Center. “It also means identifying the behaviors or thoughts that lead patients to poor health decisions. An example is a patient who just had a heart attack but continues to smoke and eat poorly. Behavioral health clinicians can help address the habits or underlying thought processes that lead someone to do this.

“But also, when patients have uncontrolled mental health issues such as depression or anxiety, their ability to care for their chronic diseases is diminished,” she says. “A patient with uncontrolled major depressive disorder will have disordered sleep, disordered eating habits, lack of motivation to do things that used to bring them pleasure, and lack of motivation to leave the house for doctor visits or to take their medications.”

Where we stand today

Today, 118,500 primary care physicians are co-located with nearly 140,000 behavioral health clinicians in 23,000 primary care practices (20% of primary care physicians, 19% of behavioral health clinicians, 38% of primary care practices), according to the Robert Graham Center.

“If co-location means actual integration, this is a great start,” says Dr. Jabbarpour. “But a couple caveats. Just because a primary care physician and behavioral health clinician are co-located does not mean they are on the same floor or in the same office. Even if they were, it does not necessarily mean that they work hand-in-hand. Also, the distribution of these providers may not be equal. There may be areas of high behavioral health need that lack integrated behavioral health practices, and areas with lower need that have more than one BHI practice. BHI is growing but I would not say supply is sufficient to meet the demand.”

Begins with screening

Behavioral health integration offers convenience for the patient and family, efficiency in consultation, better communication, treatment adherence, co-management, family buy-in and reduction of stigma, says Marian Earls, M.D., MTS, FAAP, chair of the American Academy of Pediatrics Council on Healthy Mental and Emotional Development and chair of the AAP Mental Health Leadership Group, which is focused on mental health integration in pediatric practice. “In addition, it eliminates the knee-jerk reaction of immediately referring for concerns. The wait times for a referral can be significant. Even if a referral is made, primary care intervention … and follow-up can begin immediately.”

Routine screening optimizes prevention and early identification, she says. “Every child should have a social/emotional screen, appropriate for age, at each of their well visits. Regardless of result, the screen is discussed with the family. If it shows concerns, engaging the patient and family in secondary screening and planning, providing diagnostic evaluation (or referring for evaluation), management, co-management with a mental health specialist if indicated, and regular follow-up would occur.”

No single model

Successful integration of behavioral health care can occur along a spectrum, from coordinated to fully integrated care, with the Collaborative Care Model (CoCM) being one of the models.

In the Collaborative Care Model, a care manager coordinates care of the patients with significant mental health concerns which call for the consultation of a psychiatrist, says Dr. Earls. This model requires that the practice maintain a contract with a psychiatrist and a registry of such patients. The care manager communicates with the psychiatrist and shares recommendations with the primary care provider.

“But this model has limited use in pediatrics,” she says. “Most mental healthcare in the pediatric setting involves children and adolescents with functional issues or concerns that don’t rise to the level of a DSM-5 diagnosis,” that is, a standard classification of mental health disorders. “For those who do have a DSM-5 diagnosis, the needs are primarily mild to moderate. In addition, the significantly limited number of child and adolescent psychiatrists makes wide availability for contracting with practices unlikely.

A second model – the Primary Care Behavioral Health Model – is more consistent with pediatric practices, say Dr. Earls. In this model the mental health clinician is a member of the family-centered medical home team and:

  • Participates in morning “huddles.”
  • Partners during routine visits and provides immediate triage and response to positive screens.
  • Gets involved routinely in visits for children with chronic/complex conditions.
  • Provides self-management counseling for patients with chronic medical conditions.
  • Engages in “warm handoffs,” that is, handoffs conducted in person between the medical and behavioral health team, often in front of the child and family.
  • Provides liaison with the mental health specialty system, schools, and agencies.
  • Monitors the child’s/adolescent’s course.

Doctors benefit too

Behavioral health integration benefits doctors and staff as well as patients and their families, according to adherents.

Integrating a mental health professional in pediatric practice provides cross-fertilization, or bi-directional learning between primary care clinicians and mental health clinicians, says Dr. Earls. “Primary care clinicians become more comfortable interpreting screening, having conversations with patients and families, providing follow-up and understanding community resources. Meanwhile, mental health clinicians become more knowledgeable about routine preventive care, development and the mental health needs associated with chronic conditions.

“When we first decided to do this, people knew we needed help but didn’t know the model,” says Dr. Earls, speaking of her experience with behavioral health integration dating back 20 years. At the time, she was medical director of Guilford Child Health (now Triad Adult & Pediatric Medicine), a nonprofit practice in Greensboro, North Carolina, which primarily served kids from families living under 200% of the federal poverty level. “We knew if we just put a mental health clinician down the hall and referred kids, their schedule would fill up quickly, limiting capacity. So we didn’t want a traditional model,” she says.

“Our practice had a fairly large percentage of children and adolescents with chronic medical conditions. One example would be those with sickle cell disease – a main stressor. They may miss school because of pain, and their parents might miss work to take care of them. Add to that the stress of hospitalization.” Pediatric practices deal with a host of other issues, such as the adolescent with type 2 diabetes who has decided to stop taking meds, or children with severe asthma or developmental issues.

“Before behavioral health integration, we might refer a family to a mental health agency, but we didn’t know who they were going to see, and we could only hope they would be matched with someone with expertise with the age group,” says Dr. Earls. “That was especially difficult because at the time, a lot of public mental health work was done predominantly with adults, often with significant issues. Kids and their parents can feel very uncomfortable in a waiting room full of adults with diagnosed mental health issues. And later we might find out they never got to a mental health clinic at all, or they weren’t satisfied with the care they received.

“With an integrated mental health clinician, we were better able to make a ‘warm handoff’ to a community mental health clinician for treatment when indicated, and to co-manage.”

The Primary Care Behavioral Health Model was a good fit for Guilford. Soon clinicians were clear that they would not want to practice any other way again, she says.

Moving forward

Primary care practices often find that reimbursement for behavioral health is inadequate.

“When a clinician has a visit with a patient, they get paid,” says Dr. Jabbarpour. “This leaves out non-billing members of a healthcare team who are essential to behavioral health, like social workers and therapists. Additionally, if a clinician wants to collaborate with a billing behavioral health provider, such as a psychiatrist, they don’t get paid sufficiently for that time.

“In order for these practices to stay viable and serve patients in their communities, we need payment reform that moves us towards paying for teams to deliver care and not clinicians to deliver services.”

The BHI Collaborative points out other obstacles that primary care practices face when trying to implement behavioral health integration:

  • Lack of necessary upfront capital, including required training and resources.
  • Complex and burdensome billing requirements, particularly in fee-for-service situations and narrow/carveout networks.
  • Out-of-pocket patient costs associated with integrated services, which can deter patients from seeking such support.
  • Difficulty estimating the net effects of behavioral health integration. “Without a convincingly calculated return on investment, it is challenging for physicians to confidently invest in resources to sustain BHI efforts in their practices,” according to the Collaborative.
  • Federal and state regulations that make it difficult for practices to share patient information across care team members.
  • Difficulty finding and retaining a workforce trained in integrated care.

“More people than ever are struggling with their behavioral health, including both mental health and substance use disorders,” write the authors from the BHI Collaborative. “By working collaboratively to address both physical and behavioral patient concerns in primary care, we can begin to properly use BHI to enable holistic health care for all.”

Says Dr. Jabbarpour, “Just as there is a shortage and maldistribution of primary care, there is a shortage and maldistribution of behavioral health providers. Both workforces need to be bolstered to meet the demands of the population.”

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