Why Integrate Behavioral Health?

Bottom Line, Up Front

Providing primary care and mental healthcare via models we have been using for the past 40 years is no longer tenable. Many indices of American health remain low while costs of our healthcare consistently rise.

Historically, primary care lacks the mental health component that is critical for improving patients’ health.

Current models for delivering mental health are incomplete and missing components necessary to effectively care for the continuum of mental health difficulties.

Integrated behavioral healthcare (IBH) creates a “step” in a medical system that has been absent because historically the mental health field specialty has operated in a silo, serving as a “one size fits all” for mental health conditions that patients present to their primary care providers, and providing little to no services for behavioral aspects of general health conditions.

Mental health care and primary care redesign complement one another. Both warrant new models for workflow; new tools and systems for data collection and documentation; changes in clinic culture, staff, and patient expectations; and fundamental differences in how we deliver care to our patients.

Historically, physical health and mental health have been treated functionally as two separate problem areas. However, in the past 40 years, a growing body of research has demonstrated the connection between physical and mental health. As delineated in Engel’s landmark 1977 article “The Need for a New Medical Model: A Challenge for Biomedicine,” to obtain optimal health outcomes, the medical field must attend to the patients’ psychological, social, and environmental aspects of their lives as well as their biology.(1)

Since Engel’s influential paper, immense research has been conducted on health determinants — those variables that lead to positive or negative health. While some of those health determinants are environmental, economic, cultural, or social, others are specific to the patients themselves.

We now know that many of the determinants of poor health in America boil down to simple patient characteristics that are subject to modification without medication or other procedures. Addressing these patient characteristics helps patients achieve better health, often at lower costs to the system. For example, the majority of the variables driving the top 10 causes of death in the United States are attributable to nongenetic and nonbiological factors, and 40 percent of the factors contributing to premature death in the United States are due to behavioral factors.(2,3)

Patient and family engagement, shared decision making between patient and provider, increased health literacy among patients, improved management of health behaviors (e.g., eating, physical activity, smoking), increased patient engagement and motivation, communication, and trust between patients and providers have all been found to improve illness prevention and chronic disease management, sometimes at lower costs.(4-11)

Many of the determinants of poor health in America boil down to simple patient characteristics that are subject to modification without medication or other procedures. Addressing these patient characteristics helps patients achieve better health, often at lower costs to the system.

Health is no longer as simple as a “physical or mental problem the doctor fixes.” Rather, there is growing focus on practical, patient-centered healthcare delivery, where primary care providers (PCPs), behavioral health providers (BHPs), and patients work together to make informed decisions about the best courses of action for optimal physical and mental health. These decisions may include improving medication adherence, adopting a healthier diet, or becoming more physically active.

Each of these health-related changes is managed by the BHP in conjunction with the PCP. Studies have shown that this arrangement can improve mental health conditions like depression as well as health conditions such as diabetes.(12) Systems that improve information accessibility and sharing, as well as coordination of care across the multiple levels of stepped care, deliver improved outcomes at lower costs through fewer readmissions, fewer unnecessary appointments, less unnecessary emergency department use, and reduced inpatient costs.(13)

Despite the research substantiating how biology, psychological responses, social interaction, and the patient’s environment all contribute to the patient’s health, many facets of the U.S. healthcare system continue to operate with a reductionist approach, separating physical or general health from mental health.

For example, consider that nonpharmacological interventions may be first-line treatments for several of the most common problems seen in primary care (e.g., depression, insomnia, obesity, tension headaches, tobacco use), yet these services often are not available or not ordered by PCPs.(14) In addition, some of the most effective adjunctive treatments for problems like chronic pain, irritable bowel syndrome, and hypertension involve evidence-based psychosocial interventions — those that aren’t medications, devices, or medical procedures. In short, this is how behavioral health benefits patients in the medical home.

Yet, the medical system previously had not been primed to incorporate these treatments. Not surprising, the recent past (and sometimes still existing) healthcare payment models reinforced this mindset, along with the years of delayed dissemination and implementation of evidence-based care in training and practice. Even if these barriers are reduced/eliminated, a PCP cannot do it alone;(15) therefore, integrating appropriately trained BHPs as healthcare team members is important for elevating and extending the care delivery of the entire team. For our purposes, we use the term BHP to mean any integrated behavioral health provider in the medical home who can practice independently.

Integrating Behavioral Health Services Into the Medical Home

Some may wonder what the benefits are to integrating behavioral health into the medical home. Most of the skeptics we have met simply are not well informed or have had a prior negative experience with integration that, in our estimation, was not a high-quality effort in the first place. The following list provides the rationale for integrating behavioral health into the medical home.

• Reason 1: Between 30 percent and 50 percent of patients referred by a PCP to outpatient mental health care never make it to their first appointment.(27,28) Furthermore, 50 percent of PCPs report that they can “never, rarely, or sometimes” access high-quality mental health providers to which they can refer their patients.(20) Having integrated BHPs ensures that the team has access to a high-quality provider who can work with the patient and the team on a range of problems and increases the chances that a patient will make that first BHP appointment.

• Reason 2: Compared to routine primary care, enhanced primary care behavioral health services deliver superior health outcomes for these conditions: chronic pain, diabetes, obesity, alcohol abuse, tobacco use, depression, generalized anxiety disorder, social anxiety disorder, and panic disorder.(29-41) Positive outcomes also have been found for primary insomnia using integrated BHPs.(42-44) There is often an undetermined wait time for specialty mental health services.

• Reason 3: Integrated BHPs typically can provide on-demand same-day services before, after, or in conjunction with appointments with other team members.

• Reason 4: Integrated BHPs can assist with selection and implementation of appropriate screening measures to identify and treat mental health issues that may improve overall health, quality of life, and functioning. Unfortunately, many primary care settings are ill-prepared to manage mental health needs, as reflected by poor detection rates of mental health issues.(17,18)

• Reason 5: Despite limited psychosocial treatment options(19,20) between 40 percent and 60 percent of patients with psychological disorders are still treated exclusively within primary care.(21-23) A growing list of studies(24, 25) show that integrated behavioral health in primary care produces superior outcomes to traditional primary care services.

• Reason 6: The prevalence of medically unexplained symptoms in primary care range from 20 percent to 74 percent.(26) These complaints often are related to adverse childhood experiences (e.g., trauma), current stress, or worry or distress; therefore, behavioral health interventions may be helpful.

• Reason 7: Lower health literacy is consistently associated with increased hospitalizations, increased emergency care use, reduced use of mammography, reduced vaccination against influenza, decreased ability to take medications appropriately, decreased ability to interpret labels and health messages, and, among seniors, poorer overall health status and higher mortality.(16) All of this contributes to higher medical expenses and poorer outcomes. Research on interventions for health literacy finds moderate health effects using intensive self-management interventions on health behaviors and disease-management interventions on disease prevalence/severity.(16) Integrated BHPs can develop, deliver, and assist other team members (e.g., nurses, medical assistants) in improving patients’ understanding of their health.

Integrating behavioral health services into primary care corrects the historical error in how we understood mental health — as separate from physical health and always as an exceptional need. We have been using a small, specialized, expensive asset (outpatient mental health services) to treat any problem that was not considered “physical,” even though the problem may have warranted a less-intensive but “nonmedical” treatment that could be efficiently and effectively delivered in primary care.

Integrating behavioral health services into primary care creates an additional level (step) of services that are appropriate for many primary care patients. It avoids underserving (primary care as usual) or overserving (specialty mental health services) the needs of the patient and provides an additional level of care coordination so those who truly need specialty services can be assisted in getting that care. IBH also facilitates increased care coordination, which advances the goals of the medical home.

One historical decision tree has become obsolete: No longer do PCPs ask themselves, “Is this a physical or mental problem?” Rather, they ask, “How can our integrated BHP help my patient with the aspects of care I don’t have time to address or that I would prefer to have someone else on my team address?” For more about the benefits of integrated care, consider reviewing the California Mental Health Services Authority resources at www.ibhp.org .

Integrating behavioral health services into primary care corrects the historical error in how we understood mental health — as separate from physical health and always as an exceptional need.

IBH is no panacea, but it does have high value and is the only required integrated specialty for NCQA PCMH recognition. Like primary care, behavioral health care is undergoing the most drastic redesign the medical profession has seen in the past half century. The commitment required to launch a medical home is similar to that needed to integrate behavioral health services. Both warrant new models for workflow; new tools and systems for data collection and documentation; changes in clinic culture, staff, and patient expectations; and fundamental differences in how we deliver care to our patients. You really can’t have one without the other. As Frank DeGruy, a leader in the field of integrated primary care has stated, “…without behavioral health, the medical home fails.”

Adapted from the book Integrating Behavioral Health into the Medical Home: A Rapid Implementation Guide. www.physicianleaders.org/integrating-behavioral-health.

References

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