Behavioral health refers to the array of professional services delivered to populations suffering with mental illnesses, substance use disorders and maladaptive health behaviors, such as lack of exercise, poor dietary habits and lackluster engagement in care.
Integrated care is a general term for any attempt to fully or partially blend behavioral health services with general and/or specialty medical services. This blending can occur within inpatient or ambulatory clinical settings.
Access to existing mental health services is severely limited, and unlikely to improve if the system continues to rely on traditional referral methods. There is substantial evidence that providing improved access to quality behavioral health care can:
- Save substantial amounts of money when managing chronic medical conditions;
- Prevent costly hospitalizations;
- Dramatically improve physical health outcomes; and
- Improve clinician and patient satisfaction.
In addition, because of convenience and stigma, many patients are more willing to access mental health treatment when provided at their routine doctor’s office than at a specialty mental health clinical setting.
The best models of integrated vary, with intensive, multi-disciplinary team supports, allowing a primary care provider (PCP) to greatly expand their repertoire for behavioral health treatments. With assistance for patient outreach, engagement and follow-up, as well as tailored evidence-based recommendations, rates of improvement for common mental health conditions, such as Major Depressive Disorder, can be more than doubled when compared to existing care.
PCPs are already managing mental illness and substance use disorders and are often frustrated with the extra work of collaborating with mental health clinicians outside of their typical referral network. They also express frustration with trying to keep up with evidence-based management of common conditions. Quality integrated care programs substantially reduce the workload for PCPs through seamless communication and effortless expert consultation, vesting mental health outcomes solidly within a team-based framework that patients and clinicians alike can benefit from.
The Collaborative Care Model
The Collaborative Care Model (CoCM) allows your primary care system to know who is not well with their mental health, engage patients, and proactively manage their care with a team until they improve or are referred to more intensive services.
Researchers have been attempting to blend behavioral health and primary care services for decades, and a mature body of scientific literature has identified a particular model of integrated care — the Collaborative Care Model — as being cost effective, significantly improving health outcomes and delivering on patient and provider satisfaction. A 2012 Cochrane Review concluded that CoCM had significant effects for improving depression and anxiety outcomes in primary care based off of 79 randomized-controlled trials (Archer et al., 2012).
The Collaborative Care Model operates through five principles including:
- patient-centered team care
- population-based care
- measurement-based treatment to target
- evidence-based care
- accountable care.
Experience has shown that when these five principles are combined, the Collaborative Care Model — through large–scale implementations — can be held accountable to care and outcomes for populations of patients and rewarded for their performance (Unützer et al., 2012).
Alternatives to the Collaborative Care Model, including the co-located Behavioral Health Clinician (BHC) model and systematic Screening, Brief Intervention and Referral to Treatment (SBIRT) can be helpful initial first-steps towards fully integrated care services, but are not as easily measured and are less studied. Advantages of the BHC model and SBIRT, which place a clinician with a more advanced behavioral health skillset in primary care, are that they may fit better into existing, parallel workflows of primary care (i.e. require less system transformation) and may be able to bill for their services through traditional volume-based reimbursements.
The Centers for Medicare and Medicaid have announced billing codes for use by primary care providers to fund the Collaborative Care Model beginning in January 2017. Commercial payers around the country are now reimbursing for services delivered in CoCM – although, coverage and reimbursement varies by state, plan, and product.
A Collaborative Care team consists of a PCP, behavioral health care manager (BHCM), and a Consulting Psychiatrist.
- The Consulting Psychiatrist and the BHCM meet about once a week–typically by phone– for an hour or two to review the registry with the BHCM’s caseload of 40-60 patients with uncontrolled depression or anxiety identified through screening in the primary care clinic.
- Individually tailored treatment modifications that arise out of the caseload review are shared with the PCP assigned to each of the patients. The PCP assimilates the recommendations of the treatment team with the patient’s overall treatment plan and initiates or modifies pharmacological treatments, orders tests, or conducts further assessments.
- The full-time BHCM engages patients in their health care, provides targeted behavioral interventions and empowers patients toward self-management of their mental health. The BHCM is also in charge of enrolling and discharging patients from the program upon demonstration of consistent improvement, and liaising with all aspects of the treatment team.
To implement the Collaborative Care Model, a clinic should have the following resources:
- A full-time or shared BHCM;
- Protected hourly time for a consultant psychiatrist (1-2 hours/week);
- Percentage of protected time to incentivize PCPs to periodically communicate and participate in the care coordination;
- Technological resources to share a population-health registry tracking depression scores, anxiety scores and progress in treatment for enrolled patients; and
- Systematic screening protocols.
Many clinics have already invested in multiple components of the Collaborative Care Model, including universal depression screening as recommended by the United States Preventive Services Task Force (USPSTF) in early 2016. Further resources for getting started can be found online at APA's Collaborative Care Model page, and at the University of Washington's Advancing Integrated Mental-Health Solutions (AIMS) Center. Links to additional resources are included below.
The role of the Behavioral Health Care Manager (BHCM) is an evolving role in health care that is challenging to exactly define. The best BHCMs are warm, empathic individuals with excellent communication skills. They must be able to organize information and follow-up on tasks, work well with patients and members of the treatment team, be amenable to feedback, and capable of advocating for their patients.
BHCMs with nursing or psychological therapy backgrounds can be especially effective, as they may be more experienced working in primary care or medical settings. They are also typically better versed in specific psychotherapies like behavioral activation and problem-solving therapy for managing common mental illnesses such as depression. Systems that support, educate and offer feedback to their BHCM workforce will have consistently better outcomes.
Psychiatrists have a particularly broad-based skillset spanning in-depth pharmacological and behavioral management of mental health disorders, including substance use disorders. Because of their experience and perspective, they are well poised to greatly advance the evidence-base of the care provided by the interdisciplinary team, provide depth for treating complex populations, and consultation and referral linkages for emergency situations that arise in the course of treatment. Psychiatric consultation can be useful across the spectrum of severity in presentation, and a helpful educational tool for PCPs and BHCMs alike. Evidence from large-scale Collaborative Care interventions have demonstrated improvement in outcomes tied, in part, to frequency of psychiatric consultation and caseload review (Whitebird et al., 2014). The APA is training 3,500 psychiatrists in the Collaborative Care Model by 2020, priming the workforce for an evolution in access to psychiatric services and expertise.