Where do people who suffer from behavioral health disorders receive healthcare services? The answer is:  It depends.  It largely depends on the severity of their symptoms, it seems.    

According to Dr. Gary Oftedahl of the Institute for Clinical Systems Improvement in The DIAMOND Initiative: A First Year Report approximately 75 percent of all patients with depression are treated by their primary care providers. The typical patient in this setting likely presents with mild to moderate symptoms and has commercial health insurance. Should the primary care provider suggest a referral to a behavioral health professional, the patient would have a low probability of following through with the referral. The stigma associated with behavioral health care blocks the path to specialty behavioral healthcare. It is more socially acceptable to receive services in a primary care setting. Historically, primary care providers have done a fair job in treating behavioral health disorders.   

There is another group of people to consider. Individuals who suffer from serious mental illness, addictive diseases, co-occurring mental illness and addictive diseases, or severe emotional and behavioral disorders tend to seek treatment with specialty behavioral healthcare providers.   This population is much more likely to follow through with treatement in behavioral healthcare settings than in primary care. The typical patient presents with severe symptoms and is uninsured, under-insured, or has Medicaid or Medicare. Unfortunately, this group is also less likely to follow through with primary care prevention or treatment needs.  A 2009 study published in the Journal of the American Board of Family Medicine (JABFM), Health Care for Patients with Serious Mental Illness: Family Medicine’s Role reports that cardiovascular disease is the leading cause of death among people with serious mental illness; approximately two to three times that of the general population. Causes are attributed to poor access to and use of quality health care.  Negative cardiometabolic effects of some new medications increase rates of obesity, diabetes, and hyperlipidemia. Symptoms often go untreated until emergency services are required. 

The integration of behavioral health and primary care is a viable solution to accessing needed services. However, it is not possible to have one model that works for everyone. Some people are most comfortable (and therefore, much more likely to follow through with treatment) obtaining all healthcare services in a primary care setting. In this medical/healthcare home model, behavioral health services are integrated into primary care settings. A behavioral health professional works closely with primary care staff, often immediately available for a consult. The patient is able to receive both primary care and behavioral health services concurrently.

The integration of primary care into the behavioral health setting is most effective with the second group, individuals who suffer from serious mental illness or other behavioral health disorders. One way of creating this medical/healthcare  home model is for a primary care provider to work collaboratively onsite with the behavioral health provider in the behavioral health setting. This partnership ensures the total healthcare of the patient. An effective model is illustrated in this 2010 abstract published in the American Journal of Psychiatry A Randomized Trial of Medical Care Management for Community Mental Health Settings: The Primary Care Access, Referral, and Evaluation (PCARE) Study by Dr. Ben Druss, et al. 

The concept of medical/healthcare home offers new and exciting insights into how we approach healthcare needs among individuals with behavioral health needs. Perhaps it is the key to eliminating the health disparities of this vulnerable population.