Behavioral Health – Primary Care Integration: Choosing a Model

Which Models Work Best?

There are several model programs for behavioral health and primary care integration in the United States that are currently demonstrating outstanding results, such as Cherokee Health Systems, Intermountain Healthcare, and Washtenaw Community Health Organization. However, to quote Dale Jarvis, of Dale Jarvis and Associates, a national consultant specializing in payment and reimbursement system redesign, financial modeling, and business systems design for healthcare purchasers and providers: “All healthcare is local.”  Behavioral health – primary care partnerships can learn much from the model programs but will need modification to meet the unique needs of their communities. A model that is successful in a rural community may not be effective in an urban setting. State regulations greatly impact the success of various models as well, especially if the model relies heavily on funding sources that may have significant differences from state to state.

The promotion of  behavioral health and primary care integration has been identified nationally as holding promise for improved health outcomes and increased efficiency in the use of healthcare dollars. The United States Department of Health and Human Services, (HHS)  is funding 56 Primary and Behavioral Healthcare Integration (PBHCI) projects in an attempt to identify effective means of integrating healthcare. HHS, in collaboration with the Office of the Assistant Secretary for Planning and Evaluation (ASPE), seeks to answer three questions about the integration of primary and behavioral healthcare, as noted in this excerpt from the 10/21/10 SAMHSA webinar, Primary and Behavioral Healthcare Integration by Trina Dutta:

  1. Outcome Evaluation: Does the integration of primary and behavioral health care lead to improvements in the behavioral and physical health of the population with serious mental illness (SMI) and/or substance use disorders served by the grantees’ integration models?
  2. Process Evaluation: Is it possible to integrate the services provided by primary care providers and community-based behavioral health agencies (i.e., what are the different structural and clinical approaches to integration being implemented)?
  3. Model Evaluation: Which models and/or respective model features of integrated primary and behavioral health care lead to better mental and physical health outcomes?

(Contractor: RAND Corporation)

In a collaborative effort between the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and Services Administration (HRSA) a training and technical assistance center, the Center for Integrated Health Solutions, is available for PBHCI grantees and other organizations that are integrating behavioral health and primary care services. The Center for Integrated Health Solutions is a division of the National Council for Community Behavioral Healthcare.

Outcome Measures in the Behavioral Health – Primary Care Integration Partnership

It is all well and good to say that the integration of behavioral health and primary care is beneficial, even vital, to the improvement of health outcomes for people who have a serious mental illness.  However, unless we are able to provide evidence of such, it remains merely speculation. But how can we provide evidence?

Measuring Outcomes

Tracking outcomes allows for determining whether the healthcare interventions are effective. It is particularly important to screen for the following and routinely track as indicated:

  1. Body-mass index (BMI)
  2. Blood pressure
  3. Hemoglobin A1c
  4. Hyperglycemia
  5. Hyperlipidemia
  6. Family history of diabetes, hypertension, and cardiovascular disease
  7. Tobacco use history
  8. Depression
  9. Substance use
  10. Other areas as indicated

There are many screening tools and diagnostic labs that allow for screening many of the above. Ideally, these will be conducted on the initial visit to provide a baseline. Subsequent visits can focus on the areas that were identified a need and allows for tracking effectiveness of treatments.

These measurements provide an objective method of tracking response to treatment. This information is invaluable not only for treatment planning for the individual patient, but also provides data to demonstrate the effectiveness of the healthcare providers.

Demonstrating Treatment Efficacy

Electronic Health Records allow for the efficient gathering and reporting of outcomes. This data may be used as evidence of treatment efficacy, which is necessary for securing and maintaining funding (which is, of course, necessary for staying in business).  This example is from a report from a behavioral health and primary care integration team that highlights the six month outcomes from 295 people served (click here for details):  Behavioral Health – Primary Care Integration Outcomes.

In a similar collaborative effort between a community behavioral health organization and a private disease management initiative, the outcomes indicate a positive correlation between integrated efforts and follow up with health screenings (click here for details): Community Behavioral Health – Private Disease Management Collaboration Outcomes.

These two examples provide evidence of the effectiveness of behavioral health and primary care integration efforts to impact the health outcomes of people with serious behavioral health disorders.

Routine collection and reporting of data provides ongoing feedback to the team. The data allows for:

  1. Reassurance of effectiveness of methods for team members
  2. Evidence of efficacy for regulatory and funding organizations
  3. Timely identification of areas requiring calibration for increased effectiveness
  4. Potential and current patients/clients can make an informed decisions in choosing healthcare providers