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7 Strategies for Integrating Behavioral Health Into Primary Care

As we collectively address this rising tide of behavioral health needs, we will need more payment reform, more innovation, and continued migration to more prospective payment models and treatment approaches that bring all stakeholders together to care for patients in a holistic manner.

Author:  Nameeta Dookeran, MD

The behavioral health crisis in this country is well-documented and only getting worse. As a result, there is growing impatience for a paradigm shift that moves behavioral health from the periphery to the forefront of the health and wellness agenda.

One of the most effective ways to accomplish this shift is to integrate behavioral health more deeply into primary care. This would convert theoretical access into real access, improve overall health outcomes for people with mental illness and/or substance use disorders, enhance adherence with treatment recommendations, and reduce overall healthcare costs. While this benefits all patients, the return on investment is especially worthwhile for our most vulnerable populations.

Despite decades of discussions and active efforts across the country, there is still a lot of work to be done within the healthcare system to truly integrate behavioral health into primary care. Here are 7 strategies that can move us farther faster.

Expand the care team capacity

Providers are currently making noble efforts in the realm of behavioral health, particularly for anxiety and depression. However, access and quality of care can be improved by embedding behavioral health clinicians within a primary care practice. One model could include bringing in behavioral health clinicians/care managers (such as licensed clinical social workers or psychiatric nurses) and partnering them with a consultant psychiatrist.

Increase capacity and extend access via technology

Leveraging telehealth is a powerful way to extend access and support for behavioral health issues. Other tech-enabled supports include peer groups and self-management tools, such as mobile apps and other digitally enabled tools. Hybrid in-person/telehealth models can leverage virtual access to behavioral health specialists by having established care team members—like community health workers—who do in-home visits, facilitate telehealth appointments with behavioral health specialists joining remotely.

Enhance infrastructure and processes to facilitate measurement-based care

Primary care providers need effective and easy-to-use tools to assist them in delivering measurement-based care. Using standardized tools such as the PHQ-9 and GAD-7 screening for depression and anxiety, and validated screening tools for substance use disorders, can help normalize addressing behavioral health in routine primary care and increase identification of behavioral health issues. Enhanced clinical information systems and decision support tools, as well as population health management platforms, can create a strong foundation for integrated care systems and the tracking of key quality metrics.

Include home-based care in your design

Coordinating efforts with home-based care programs can bolster the effectiveness of an integrated behavioral health care approach. Other challenges can be discovered by the team being in a patient’s home in a way that simply cannot be identified in an office setting. Also, in- home support mitigates issues with access to care or transportation.

Focus case management resources

If it is possible to identify complex chronic populations where behavioral health issues exacerbate existing medical conditions, negatively impacting overall health and increasing inappropriate (medically unnecessary) utilization, this can be one area to steer care management resources. Emphasis should be placed on ensuring patients are connected to appropriate resources to meet their complex bio-psycho-social needs, and that the treatment options offered are evidence-based for substance use disorders as well as for mental health issues.

Remove cost barriers for patients

Payment change can unlock delivery change and patient partnership transformation. Health plans should consider other ways to reduce costs rather than having patients bear the cost of access to behavioral health care services. We need to move away from traditional fee-for-service models that promote continued focus on the quantity of services provided, and move toward hybrid payment models that  promote better quality of care and effective population health management strategies

Set a plan and be patient

Outcomes do not happen overnight. Integration efforts can be broken down into immediate, short -term and long-term goals. The most immediate focus should be on prioritizing access and quality of care. As access improves and stigma is reduced with care embedded in primary care, conditions will be more consistently identified. From there, the ability to facilitate timely and real access to appropriate care and other resources will improve, as will the ability to effectively measure positive clinical and financial impact that goes way beyond improvement in behavioral health.

In conclusion

We are seeing unprecedented demand for behavioral health care, alongside decreasing overall health for the U.S. population. As we collectively address this rising tide, we will need more payment reform, more innovation, and continued migration to more prospective payment models and treatment approaches that bring all stakeholders together to care for patients in a holistic manner.

This will require collaborative involvement of all stakeholders. The provision of care must be evidence-based, and reimbursement rates have to be calibrated appropriately to fund behavioral health services. Value-based models are creating more opportunities for this integration to occur, but we need to continue pushing this agenda forward. We need systematic assessment, identification, and early intervention. We need to ensure delivery of appropriate support and continuously monitor evolving patient needs while assessing the effectiveness of our efforts. None of this can happen without a truly integrated model of behavioral and physical health within primary care.

Nameeta Dookeran

Dr. Nameeta Dookeran serves as Emcara Health’s National Medical Director of Behavioral Health Care Solutions. Board certified in Internal Medicine and Addiction Medicine, she is skilled in the care and clinical treatment of people living with mental illness and substance use disorders. During her career, she has held both front-line physician and clinical leadership roles in a variety of settings, including outpatient and residential “dual-diagnosis” addiction treatment centers for opioid and alcohol use disorders. Most recently, she has served as the chair of the Education Committee for the Wisconsin Society of Addiction Medicine.

Dr. Dookeran completed internal medicine and preventive medicine residency, and general internal medicine fellowship training at Boston University. She holds an MD from the joint Dartmouth-Brown program, a Master of Science in Health Services Research from Boston University School of Public Health, and a Bachelor of Science in Chemical Engineering from Massachusetts Institute of Technology.

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