Mind and Body - Behavioral Health Integration in the Primary Care Office

Despite the fact that 85% of patients with a mental health and/or substance use disorder visit a primary care physician (PCP) at least once in a 12-month period, overdose and drug-related deaths have reached startling highs in the U.S. Approximately 75% of individuals who commit suicide have contact with a PCP within a year of their death, and 45% have contact within one month. Only 20-30% of patients with psychological issues inform their PCP about their concerns.

Mental health disorders compromise the largest share of burden of diseases in the United Kingdom. Yet most people with a mental health disorder – with the exception of psychosis -- receive little to no intervention in standard medical practices.

The Bottom Line

The prevalence and high financial and human cost of untreated behavioral conditions highlight the need to integrate behavioral and medical care. Mental health disorders have the highest care costs -- more than 200 billion USD in 2013. Additionally, medical and behavioral conditions have high rates of co-occurrence, particularly with chronic medical conditions, such as diabetes.

Co-occurring behavioral conditions affect people’s ability to manage their medical condition and can increase the cost of care two to three times that of people without a behavioral condition. A serious mental health condition reduces adult life expectancy by an average of 25 years, generally due to a co-existing chronic medical condition. Care for patients with co-occurring conditions must be coordinated, because they are more likely to be taking multiple medications, creating the risk of drug-drug interactions and introducing other complexities in the treatment plan.

Mental health disorders have the highest care costs -- more than 200 billion USD in 2013.

Implementing Behavioral Health Integration

In the UK, the National Health Service announced plans in 2018 to place more than 1,500 mental health therapists in primary care by March 2019.

Different pathways may be taken to move toward BHI:

• At one end of the spectrum is coordinated care, in which clinicians working in different settings exchange information about shared patients.
• In the middle of the BHI spectrum is co-location, in which the behavioral health specialist is physically located in a primary care clinic, or the primary care physician or other clinician is physically located in a mental health or substance use disorder treatment setting.
• At the other end of the spectrum is integrated care, where the practice team includes primary care and behavioral health physicians and other clinicians working together with patients and families, using a systematic, seamless approach to provide patient-centered care.

BHI models of care are not meant to meet the needs of patients with complex mental health issues, for example, bipolar disease, schizophrenia, or unstable psychosis, etc. or those who require urgent referral for psychiatric care and/or inpatient behavioral care (e.g., substance withdrawal or detoxification, suicidal ideation, violent or destructive behavior). Practices should have protocols in place for referral or transfer when urgent or life-threatening conditions and needs are identified.

What’s Standing in the Way?

Barriers to behavioral health integration include stigma, shortages of behavioral health services and providers, and lack of financial resources to invest in the necessary infrastructure to achieve and maintain practice changes.

One of the most significant issues slowing care integration relates to data-sharing. Many providers, particularly behavioral providers, lack interoperable information systems to share data and coordinate care. In some cases, legislation prevents them from sharing data. For example, patient privacy laws in the U.S. allow disclosure of Personal Health Information (PHI) without patient consent between providers for treatment purposes with the exception of “psychotherapy notes,” which require authorization for disclosure. Stringent rules exist around substance use disorder, such as the requirement to maintain separate substance use treatment records.

The Potential

Anecdotal evidence points to the effectiveness of BHI. In 2015, TriHealth, a Cincinnati, Ohio-based health system, developed a patient-centered approach to integrating behavioral health into primary care practices. During the grant period:

• Patients showed improved mental and physical health scores.
• Ninety-five percent of participating primary care physicians reported increased job satisfaction and improved ability to meet their patients’ needs.
• Patient access to same-day behavioral health visits was shown to be one of the most beneficial components of integrated behavioral health.

TriHealth continues to build its capacity to make these services available at each of its 38 primary care practices.