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When patients seek treatment for any condition at a primary care clinic in the Intermountain Healthcare system in Utah, they get care for whichever condition brought them to the clinic. But they also get a bonus: screening and, if needed, treatment for behavioral health concerns.
"When we were improving our care processes for diabetes and asthma 15 years ago, we said to the CEO that it's great we're improving care for these diseases, but what are we going to do about the behavioral issues we are seeing?" says Brenda Reiss-Brennan, PhD, APRN, the mental health integration director at Intermountain Healthcare. "So we decided to pilot a program that integrates behavioral health care into the primary care system, and that is now fully operationalized."
Brenda Reiss-Brennan, PhD, APRN, Intermountain Healthcare
The system Reiss-Brennan and her colleagues developed has succeeded: Not only have patients reported improved overall health, but an internal study conducted 10 years into the program showed that the rate of cost increase for patients who had depression and were involved in the program was 27 percentage points less than for those who had depression and were not in the program.
"This is consistent with the intended impact of the … intervention, whereby those patients with timely diagnosis and collaborative primary care require less intensive, higher-order treatment (i.e., inpatient admission/use of the ED [emergency department])," notes the study, which was published in the March/April 2010 issue of the Journal of Healthcare Management.
Intermountain's experience provides evidence that integrating behavioral health care into the overall healthcare system improves patient results and reduces costs. As health care moves closer to a population care model, understanding the value of this integration becomes increasingly important. With the National Institute of Mental Health conservatively estimating the annual healthcare costs of treating serious mental illness at $100 billion, plenty is at stake financially as well as for patients and entire communities.
Traditionally, behavioral health issues have been treated separately from physical health issues. The distinction, in both how such conditions were treated and how society viewed them, was clear—and it lingers in many segments of health care.
"The issues that come up over and over again for patients and their families that stand in the way of integrated care are that we don't pay for care in the same way for behavioral health and for physical health, and that there is stigmatization of behavioral health issues," says Marci Nielsen, PhD, MPH, CEO of the Patient-Centered Primary Care Collaborative, a not-for-profit membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home.
"We think of the mental health system for depression and substance abuse and anxiety, but so often people with chronic illnesses have behavioral issues that also need to be addressed. When we integrate the two, we can treat all of those conditions."
Marci Nielsen, PhD, MPH, Patient-Centered Primary Care Collaborative
Despite the lingering societal disconnect between behavioral care and physical care, the connection between mind and body is not in doubt among healthcare professionals. Physical illnesses affect behavioral health, and behavioral disorders affect physical health.
"When you look at the top five chronic health conditions driving healthcare costs—depression, obesity, anxiety, back and neck pain, and arthritis—you see that all five have a behavioral health component," Nielsen notes.
When care for both sides of the mind-body connection is integrated, as is done at Intermountain Healthcare, patient outcomes improve. Data back up this assertion: A meta-study published in the Aug. 10, 2015, issue of JAMA Pediatrics examines the results of 31 studies and finds significant benefits of integrated behavioral care. The abstract of the study reads, in part: "The probability was 66% that a randomly selected youth would have a better outcome after receiving integrated medical-behavioral treatment than a randomly selected youth after receiving usual care. … Our results, demonstrating the benefits of integrated medical-behavioral primary care for improving youth behavioral health outcomes, enhance confidence that the increased incentives for integrated health and behavioral health care in the U.S. health care system will yield improvements in the health of children and adolescents."
Healthcare systems that integrate behavioral health into standard care are experimenting with different models. Common factors include some level of involvement with the patient's primary care physician (PCP) and actual or anticipated cost savings.
Intermountain Healthcare. The Salt Lake City-based health system's model of integrating behavioral care is centered on three levels of need. When a patient at any Intermountain Healthcare clinic or primary care office shows signs of a behavioral health problem—such as social withdrawal or sudden change in appetite—the patient is given a mental health integration screening packet that includes an assessment of behavioral health and chronic disease risk factors. Using the information from the screening, the caregiver decides whether the patient needs routine behavioral health care, collaborative care, or specialty care.
Routine care is provided by a PCP and support staff when a patient screens for mild depression. A patient who shows signs of moderate depression or has comorbid conditions may be placed in the collaborative care environment, which includes treatment by a mental health specialist and a case manager. Patients with more severe behavioral health issues—those deemed to be in danger or who have serious comorbid complexities—are referred to specialty care. In each case, the PCP remains involved, and the PCP support staff can guide patients and families through the designated care regimen.
"In our view of health, behavioral health issues and physical health issues are all interrelated," Reiss-Brennan says. "So if someone comes in for diabetes, they are automatically screened for depression. Thirty-two percent of diabetes patients will have depression, and we know the red flags to look for. If a diabetic patient's mood is getting out of control, they can call the care manager, and the care manager may say, 'Let's not worry about diet right now, let's take care of the depression.'"
The integrated collaboration among the PCP, support staff, and mental health professionals is key to the Intermountain Healthcare program.
"The whole team works together, meets regularly to discuss patients, and keeps everyone in the medical home fold," Reiss-Brennan says. "We have great data showing that if you are treated in a clinic with team-based care, quality indicators improve, people go to the ED less, and overall costs go down."
The reduction in costs is an important result of the program. Intermountain Healthcare, a not-for-profit system that includes 22 hospitals and 185 physician clinics, operates an insurance plan and thus carries risk with some of its patients. That risk will increase as the system ventures further into population health.
"We feel that as we move to population health, managing high-cost patients with team-based care, and identifying and managing behavioral health issues before they get costly, is the right way to go," Reiss-Brennan says.
Carolinas HealthCare System. A South Carolina-based network of 39 hospitals and more than 900 additional care locations, Carolinas HealthCare System operates a slightly different model of integrated behavioral care.
For the past 20 years the system has operated a behavioral health call center that receives 250,000 calls per year. The call center serves as a community behavioral health crisis hotline and is staffed by licensed counselors 24 hours a day. The call center also serves as a referral hub for patients and providers seeking services.
In addition, psychiatrists at Carolinas HealthCare System began providing telepsychiatry services in acute care EDs about 15 years ago. In 2013, building on this experience in virtual care delivery, CHS focused on integrating behavioral health services across the entire continuum of care.
The existing ED telepsychiatry model expanded to encompass the patient experience from arrival to the time the patient is discharged or transported for inpatient care. Patients entering the system through the ED are administered a suicide risk screening, and those who screen positive are scheduled for a telepsychiatry session, where a full risk assessment is completed.
"After the telehealth evaluation, our psychiatrist enters treatment and medication orders directly into the patient's electronic medical record [EMR], allowing treatment to begin immediately," explains Martha Whitecotton, senior vice president of behavioral health services for Carolinas HealthCare System. "If the patient needs to be placed in a higher level of behavioral care, the centralized behavioral health patient-placement team is notified to find bed placement, and a dedicated behavioral health transport system moves the patient safely to the next site of care."
Martha Whitecotton, Carolinas HealthCare System
The integration program at the health system is expanding into the primary care setting, driving early detection of illness, Whitecotton says.
"Our hope is to decrease the need for crisis intervention and impact the trajectory of illness," she says. "Through the use of a standardized screen, embedded into the EMR, primary care providers are able to identify patients in their practice who require further intervention. Depending on the result, the practice has the option to get a licensed behavioral health clinician on the video screen and do an immediate intervention or make a referral to the behavioral health integration team. The telehealth consultation is conducted through a laptop computer or iPad, real-time in the same visit. Long-term, every new patient will be screened, and every existing patient will be screened annually."
The behavioral health integration team at Carolinas HealthCare System consists of a psychiatrist, a pharmacist, licensed counselors, and health coaches. The team makes recommendations to the patient's PCP, helping the physician manage the overall health of the patient.
The team's involvement does not end after the initial consult and treatment. All patients are assigned to a behavioral health coach for telephonic follow-up to make sure they are taking their medications and understand the side effects, and to offer them the opportunity to receive behavioral therapy online, if appropriate. Coaching engagements last an average of 14 weeks and include ongoing assessment of response to treatment. All of this activity is recorded in the EMR.
"Very few of the patients need a face-to-face meeting with a psychiatrist," Whitecotton says. "It's very important to optimize the psychiatrist's time due to the manpower shortage in psychiatry. We can spread the model quickly, as our team can support multiple practices at one time, driving down the expense of providing the service."
Because the program has been fully operational only for about a year, Whitecotton says it's too early to fully calculate the ROI and overall impact on health services utilization. She says some health plans pay for virtual behavioral health care, but only when the care is delivered by a psychiatrist.
"But the whole point is that if we can get people into recovery, their health will improve, and that's the measure of effectiveness," she says. "We do know, based on follow-up PHQ-9 screening, that 89 percent of enrolled patients demonstrate decrease of at least one full severity class after health coaching."
Given that Carolinas HealthCare System is at risk for some patients in its own health plans, improving the long-term health of those patients definitely pays off. "And all hospitals are on the hook for readmissions and avoidable care, so if we can impact those measures, it's a win for the system financially," Whitecotton says.
Advocate Health Care. Based in Downers Grove, Ill., Advocate operates a third model of integrated behavioral health care. Called a "hub-and-spoke" model, the health system uses a team of behavioral caregivers based at Advocate Christ Medical Center in Oak Lawn, Ill., the largest hospital in the 12-hospital system. The team forms the hub and serves patients at several of the smaller hospitals in the system.
Advocate's program, which began in October 2014, focuses on patients 65 and older and on others as clinical judgment indicates. Anyone meeting these criteria who presents at an ED or a general medical floor is screened for depression and anxiety disorders.
"We know that chronic medical problems become more common as people age," says David Kemp, MD, co-medical director for the behavioral health service line at Advocate. "We believe it's important to screen for these behavioral disorders before they worsen. We don't have the manpower to implement this program across the board, so we're focusing on those at highest risk."
David Kemp, MD, Advocate Health Care
At one site, Advocate BroMenn Medical Center in Normal, Ill., screening is more comprehensive and includes all patients with chronic medical conditions.
Patients in the health system who are part of the program receive screening via the PHQ-9 questionnaire or the Generalized Anxiety Disorder seven-question tool. The results are sent to the hub, where the behavioral health team—which is composed of three psychiatrists, three psychologists, an advanced nurse practitioner, and a behavioral health technician—evaluates them. Mild results are reported, with the patient's consent, to the patient's PCP. More severe results are discussed with the physician in the ED; in many of those cases the behavioral health team visits the patient in person or virtually.
"The telehealth machines are on carts, so they can easily move from the ED to the medical floors and back," Kemp says. "The machine is a fairly simple design, akin to Skype, with a large monitor and a camera attached to it. So we can see the patients and talk to them in real time."
As with the programs at Intermountain Healthcare and Carolinas HealthCare System, in some cases the Advocate program has identified behavioral issues underlying physical problems. "Many times patients came in complaining of somatic problems, but behind that was a behavioral issue," Kemp says. "By addressing those we were able to prevent some admissions."
A side benefit of the program has been a reduction in the need for inpatient psychiatric care, Kemp says.
"When a behavioral health issue is present, the emergency department doctor may deem the need for inpatient psychiatric care," Kemp says. "But after evaluation, we are often able to set up in-community care instead of hospitalization."
Kemp is confident that the program will be financially worthwhile. "It's still fairly early for us to be able to analyze the financial data," he notes. "But when we looked at the sites where the model is operating compared to those without, we found a 7.5 percent lower cost per adjusted discharge for individuals with a comorbidity. Moreover, the emergency department length of stay was 11 percent lower for all sites managed by the hub-and-spoke model. Can we say it's directly attributable to the program? No, but that is one very meaningful initiative we have employed, and we feel confident it has had a significant impact given how our data set is defined."
As with the programs at Carolinas HealthCare System and Intermountain Healthcare, payment for the behavioral care Advocate is providing in this program has been inconsistent. However, Advocate has risk for behavioral health in a few of its payer arrangements, so it benefits through reduced costs for those patients.
"The data haven't been fully analyzed yet, but the response has been tremendously positive from patients and providers, and we are anticipating cost savings," Kemp says.
These three examples of integrated behavioral health are likely signs of things to come. Several provisions of the ACA should inspire more health systems to undertake such integration.
For example, the overall expansion of healthcare coverage has made more money available for behavioral care. In particular, parity rules removed the separate annual and lifetime caps on payment for mental health care.
The ACA's promotion of the medical home concept also encourages expanded integration of behavioral care with primary care.
"When it comes to the patient-centered medical home, what we have learned is that a lot of behavioral health care is being offered in the primary care setting," Nielsen, of the Patient-Centered Primary Care Collaborative, says. "Primary care providers are already serving as the de facto provider of behavioral health care, especially to those with minor mental health issues."
However, Nielsen notes, there is still a long way to go in this regard. "We have discovered that behavioral health needs to be integrated into primary care, but many struggle with the best way to do that," she says.
The accountable care organization (ACO) concept also promises to bring about greater integration of behavioral care with primary care. Because organizations involved in ACOs take on risk for the lives they cover, cost savings—such as those demonstrated when behavioral health issues are caught early and treated collaboratively—go directly to the bottom line.
Integration of behavioral health into healthcare systems thus is a trend that likely will grow in coming years, especially as leaders begin to understand the potential cost savings, increase in patient satisfaction, and improvement in overall population health. As the mind-body connection becomes better understood, its implications for health systems will increase.
Ed Avis is a freelance writer.
Interviewed for this article:
Brenda Reiss-Brennan, PhD, APRN, mental health integration director, Intermountain Healthcare, Salt Lake City.
Marci Nielsen, PHD, MPH, CEO of the Patient-Centered Primary Care Collaborative, Washington, D.C.
Martha Whitecotton, senior vice president, behavorial health services, Carolinas HealthCare System, Matthews, N.C.
David Kemp, co-medical director, behavioral health service line, Advocate Health Care.
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